Healthcare Provider Details

I. General information

NPI: 1134886955
Provider Name (Legal Business Name): THERESA SKOTLESKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 MAIN ST
PECKVILLE PA
18452-2103
US

IV. Provider business mailing address

121 S TURNPIKE RD
DALTON PA
18414-9508
US

V. Phone/Fax

Practice location:
  • Phone: 570-307-9023
  • Fax:
Mailing address:
  • Phone: 570-878-7586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW129466
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: