Provider Demographics
NPI:1124437074
Name:KRISAK, CHAD (EDS, LPES, NCSP)
Entity type:Individual
Prefix:MR
First Name:CHAD
Middle Name:
Last Name:KRISAK
Suffix:
Gender:M
Credentials:EDS, LPES, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 STONESTOWN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6690
Mailing Address - Country:US
Mailing Address - Phone:901-487-7506
Mailing Address - Fax:
Practice Address - Street 1:2907 STONESTOWN DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-6690
Practice Address - Country:US
Practice Address - Phone:901-487-7506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1588615918Medicaid