Healthcare Provider Details

I. General information

NPI: 1669942843
Provider Name (Legal Business Name): CHRISTINE LYNN SKOOG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 HILLSIDE TER
RIPON WI
54971-1605
US

IV. Provider business mailing address

627 HILLSIDE TER
RIPON WI
54971-1605
US

V. Phone/Fax

Practice location:
  • Phone: 920-266-3633
  • Fax:
Mailing address:
  • Phone: 920-748-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7630-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: