Healthcare Provider Details

I. General information

NPI: 1588100085
Provider Name (Legal Business Name): TIONNA CHANTEL CHAMBLISS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15023 21 MILE RD
SHELBY TOWNSHIP MI
48315-5024
US

IV. Provider business mailing address

6137 WINDEMERE LN
SHELBY TOWNSHIP MI
48316-5380
US

V. Phone/Fax

Practice location:
  • Phone: 586-464-0175
  • Fax:
Mailing address:
  • Phone: 586-530-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401003135
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: