Healthcare Provider Details

I. General information

NPI: 1174962013
Provider Name (Legal Business Name): BENJAMIN E. SKOWYSZ LCSW, CSOTP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12232 GAYTON STATION BLVD
HENRICO VA
23233-6623
US

IV. Provider business mailing address

12232 GAYTON STATION BLVD
HENRICO VA
23233-6623
US

V. Phone/Fax

Practice location:
  • Phone: 804-360-3988
  • Fax:
Mailing address:
  • Phone: 804-360-3988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0812000474
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904005727
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: