Provider Demographics
NPI:1376653527
Name:SCHILLO, CHARELL G (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CHARELL
Middle Name:G
Last Name:SCHILLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 874
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802
Mailing Address - Country:US
Mailing Address - Phone:701-774-4646
Mailing Address - Fax:701-774-4620
Practice Address - Street 1:316 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801
Practice Address - Country:US
Practice Address - Phone:701-774-4600
Practice Address - Fax:701-774-4620
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5261041C0700X
UT123500-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND79232Medicaid
ND019075OtherBC/BS
ND79232Medicaid