Healthcare Provider Details

I. General information

NPI: 1811048655
Provider Name (Legal Business Name): LISA SKOMRA-LOTZE MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

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

955 WINDHAM CT SUITE 2
BOARDMAN OH
44512-5035
US

IV. Provider business mailing address

955 WINDHAM CT SUITE 2
BOARDMAN OH
44512-5035
US

V. Phone/Fax

Practice location:
  • Phone: 330-884-1900
  • Fax: 330-884-1928
Mailing address:
  • Phone: 330-884-1900
  • Fax: 330-884-1928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC0005367
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: