Healthcare Provider Details

I. General information

NPI: 1194187955
Provider Name (Legal Business Name): PEGGY SUE SKOLD CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24248 STATE ROAD 35 70 UNIT D
SIREN WI
54872-5001
US

IV. Provider business mailing address

108 W 2ND ST N
LADYSMITH WI
54848-1338
US

V. Phone/Fax

Practice location:
  • Phone: 715-349-7233
  • Fax: 715-349-7205
Mailing address:
  • Phone: 715-532-9771
  • Fax: 715-532-9774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15863-132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: