Healthcare Provider Details

I. General information

NPI: 1588496574
Provider Name (Legal Business Name): ZAK ZILLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2024
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

V. Phone/Fax

Practice location:
  • Phone: 734-287-1500
  • Fax:
Mailing address:
  • Phone: 734-785-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362010163
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: