MEDICARE: STEPHANIE CHISM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1992992564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE CHISM

Provider Business Mailing Address
First Line	:	26460 SUMMIT CIR
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91350-2991
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8346 BEVERLY BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-2632
Country	:	US
Telephone Number	:	323-659-1677
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/27/2007

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Directions to “ STEPHANIE CHISM ” Practice Location

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