Basic Information
| Provider Information | |||||||||
| NPI: | 1740699065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHISCHILLY | ||||||||
| FirstName: | KRYSTALENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LSAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 BROADWAY BLVD NE STE 500 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052680701 | ||||||||
| FaxNumber: | 5052329055 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 BROADWAY BLVD NE STE 500 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052680701 | ||||||||
| FaxNumber: | 5052329055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2014 | ||||||||
| LastUpdateDate: | 08/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0159961 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.