Provider Demographics
NPI:1407456262
Name:HILLSTROM, DAWN RENEE TEREZ
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:RENEE TEREZ
Last Name:HILLSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:RENEE TEREZ
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC
Mailing Address - Street 1:50258 VAN DYKE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1374
Mailing Address - Country:US
Mailing Address - Phone:586-884-4714
Mailing Address - Fax:586-884-4693
Practice Address - Street 1:50258 VAN DYKE AVE STE A
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-1374
Practice Address - Country:US
Practice Address - Phone:586-884-4714
Practice Address - Fax:586-884-4693
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI640101875101YM0800X
MI6401018750101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401018750Medicaid