Healthcare Provider Details

I. General information

NPI: 1841740792
Provider Name (Legal Business Name): CELIA SHALLAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22151 MOROSS RD PB1
DETROIT MI
48236-2167
US

IV. Provider business mailing address

401 N YORK ST
DEARBORN MI
48128-1747
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-7230
  • Fax:
Mailing address:
  • Phone: 248-860-6515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS440112585790
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: