Provider Demographics
NPI:1194420273
Name:CHISOLM, NUNDI MAKEBA
Entity type:Individual
Prefix:MRS
First Name:NUNDI
Middle Name:MAKEBA
Last Name:CHISOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NUNDI
Other - Middle Name:MAKEBA
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:758 ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-6433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:758 ROYAL ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-6433
Practice Address - Country:US
Practice Address - Phone:225-236-2921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician