Provider Demographics
NPI:1992208250
Name:CHILLOUS, SHIMIKA RENA
Entity Type:Individual
Prefix:
First Name:SHIMIKA
Middle Name:RENA
Last Name:CHILLOUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43961 BAYVIEW AVE APT 38108
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35000 DIVISION RD STE 2
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-1566
Practice Address - Country:US
Practice Address - Phone:586-727-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty