Healthcare Provider Details

I. General information

NPI: 1275189243
Provider Name (Legal Business Name): TARYN SKODA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4447 N KEDZIE AVE
CHICAGO IL
60625-6636
US

IV. Provider business mailing address

4447 N KEDZIE AVE
CHICAGO IL
60625-6636
US

V. Phone/Fax

Practice location:
  • Phone: 216-543-0240
  • Fax:
Mailing address:
  • Phone: 216-543-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: