=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275215667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENT SKALL APRN, PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2023
-----------------------------------------------------
Last Update Date | 01/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3094 W MARKET ST STE 203
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-326-6069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14723 DELAWARE AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107-5942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-608-4894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0034479
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------