Healthcare Provider Details

I. General information

NPI: 1467129353
Provider Name (Legal Business Name): KRISTA SKODACK M.A., BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 N WAYNE RD
WESTLAND MI
48185-2713
US

IV. Provider business mailing address

51145 NICOLETTE DR
CHESTERFIELD MI
48047-4585
US

V. Phone/Fax

Practice location:
  • Phone: 586-243-0555
  • Fax:
Mailing address:
  • Phone: 586-228-9991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001650
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: