Healthcare Provider Details

I. General information

NPI: 1093228207
Provider Name (Legal Business Name): GINA M SKORICH LISW. LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 08/05/2024
Certification Date: 04/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9113 KATHERINE CT
MENTOR OH
44060-1643
US

IV. Provider business mailing address

1281 E 360TH ST
EASTLAKE OH
44095-3130
US

V. Phone/Fax

Practice location:
  • Phone: 216-466-1423
  • Fax:
Mailing address:
  • Phone: 440-269-0826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161964
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.2405690
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: