Healthcare Provider Details

I. General information

NPI: 1376653527
Provider Name (Legal Business Name): CHARELL G SCHILLO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 2ND AVE W
WILLISTON ND
58801
US

IV. Provider business mailing address

BOX 874
WILLISTON ND
58802
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-4600
  • Fax: 701-774-4620
Mailing address:
  • Phone: 701-774-4646
  • Fax: 701-774-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number526
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123500-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: