Healthcare Provider Details

I. General information

NPI: 1073805156
Provider Name (Legal Business Name): SKILL SPROUT INTERNATIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 WALNUT STREET
WASHINGTON IL
61571
US

IV. Provider business mailing address

102 WALNUT STREET
WASHINGTON IL
61571
US

V. Phone/Fax

Practice location:
  • Phone: 800-773-1682
  • Fax: 800-773-1682
Mailing address:
  • Phone: 800-773-1682
  • Fax: 800-773-1682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-6597
License Number StateIL

VIII. Authorized Official

Name: AMY SHYMANSKY
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 800-773-1682