Healthcare Provider Details

I. General information

NPI: 1992055057
Provider Name (Legal Business Name): MS. SHELLI RENEE CULLIMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

28 LIVINGSTON ST
YALE MI
48097-3312
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-8900
  • Fax:
Mailing address:
  • Phone: 810-488-0581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: