Healthcare Provider Details

I. General information

NPI: 1548079122
Provider Name (Legal Business Name): CHARLES KHALIL SHAMEY TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8512 N CANTON CENTER RD
CANTON MI
48187-1310
US

IV. Provider business mailing address

26263 LAWRENCE DR
DEARBORN HEIGHTS MI
48127-3345
US

V. Phone/Fax

Practice location:
  • Phone: 734-738-0897
  • Fax:
Mailing address:
  • Phone: 313-407-0558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362009845
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: