Provider Demographics
NPI:1063059293
Name:ISOM, ALISHA CHANTAY
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:CHANTAY
Last Name:ISOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SWINNEY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FRIES
Mailing Address - State:VA
Mailing Address - Zip Code:24330-3548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 PAINTER ST
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-3830
Practice Address - Country:US
Practice Address - Phone:276-236-5164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202009193235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist