Provider Demographics
NPI:1427460278
Name:CHISM, AYANA LAKULIA (LMSW)
Entity type:Individual
Prefix:MISS
First Name:AYANA
Middle Name:LAKULIA
Last Name:CHISM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 HUTCHENS RD
Mailing Address - Street 2:APT A
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-5228
Mailing Address - Country:US
Mailing Address - Phone:731-695-5633
Mailing Address - Fax:
Practice Address - Street 1:215 HAWKS RD
Practice Address - Street 2:SUITE 5
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-2708
Practice Address - Country:US
Practice Address - Phone:731-587-3545
Practice Address - Fax:731-587-3546
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8638104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker