Provider Demographics
NPI:1699456079
Name:CHISHOLM, MARSHALL GAVIN (BA, RBAI)
Entity type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:GAVIN
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:BA, RBAI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 NE 44TH AVE STE 390
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1461
Mailing Address - Country:US
Mailing Address - Phone:503-963-6494
Mailing Address - Fax:310-933-4134
Practice Address - Street 1:5435 BALBOA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1570
Practice Address - Country:US
Practice Address - Phone:310-933-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10234166106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician