Provider Demographics
NPI:1033819610
Name:FILLMORE, MICHAEL JAMES
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 WAUKONDA AVE
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-3142
Mailing Address - Country:US
Mailing Address - Phone:269-926-1284
Mailing Address - Fax:
Practice Address - Street 1:497 WAUKONDA AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3142
Practice Address - Country:US
Practice Address - Phone:269-926-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor