Healthcare Provider Details

I. General information

NPI: 1396743597
Provider Name (Legal Business Name): MARY E. SKIDMORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2129 SW 59TH ST MYHRO CENTER
OKLAHOMA CITY OK
73119-7024
US

IV. Provider business mailing address

2201 LANEWAY CIR
OKLAHOMA CITY OK
73159-5827
US

V. Phone/Fax

Practice location:
  • Phone: 405-713-5876
  • Fax: 405-713-5786
Mailing address:
  • Phone: 405-713-5876
  • Fax: 405-713-5786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1488
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: