Healthcare Provider Details

I. General information

NPI: 1700931789
Provider Name (Legal Business Name): MICHAEL CHARLES SKOLNIK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 BROADWAY ST SUITE 100
VALLEJO CA
94589-2226
US

IV. Provider business mailing address

1761 BROADWAY ST SUITE 100
VALLEJO CA
94589-2226
US

V. Phone/Fax

Practice location:
  • Phone: 707-645-2700
  • Fax: 707-645-2181
Mailing address:
  • Phone: 707-645-2700
  • Fax: 707-645-2181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS7233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: