Provider Demographics
NPI:1568686509
Name:SCHILLACE, RALPH JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:JAMES
Last Name:SCHILLACE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1753
Mailing Address - Country:US
Mailing Address - Phone:248-652-1303
Mailing Address - Fax:248-652-3620
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1753
Practice Address - Country:US
Practice Address - Phone:248-652-1303
Practice Address - Fax:248-652-3620
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001724103TC0700X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI62OF34573OtherPSYCHOLOGIST
MIOF34573Medicare PIN