Healthcare Provider Details

I. General information

NPI: 1760533632
Provider Name (Legal Business Name): CECILIA MAE SKIDMORE M.A., L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 WEALTHY ST SE SUITE 260
GRAND RAPIDS MI
49506-2755
US

IV. Provider business mailing address

1554 MACKINAW RD SE
GRAND RAPIDS MI
49506-3349
US

V. Phone/Fax

Practice location:
  • Phone: 616-451-3008
  • Fax:
Mailing address:
  • Phone: 616-241-2413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401001787
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: