Healthcare Provider Details

I. General information

NPI: 1174454631
Provider Name (Legal Business Name): ANTOINETTE SKELLY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 JACKSON ST
SAINT CLAIR MI
48079-5278
US

IV. Provider business mailing address

1918 JACKSON ST
SAINT CLAIR MI
48079-5278
US

V. Phone/Fax

Practice location:
  • Phone: 810-674-0556
  • Fax:
Mailing address:
  • Phone: 810-674-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501015569
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: