Healthcare Provider Details

I. General information

NPI: 1316299654
Provider Name (Legal Business Name): MS. STACIE LYN SKILLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 VIA DELLA GRECA
HENDERSON NV
89011-1701
US

IV. Provider business mailing address

327 VIA DELLA GRECA
HENDERSON NV
89011-1701
US

V. Phone/Fax

Practice location:
  • Phone: 760-267-8948
  • Fax:
Mailing address:
  • Phone: 760-267-8948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: