MEDICARE: MR. RONALD CRAIG SKIDMORE MA, MA, MDIV, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	6401010233	MI

General Provider Information

NPI Number	:	1881811941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RONALD CRAIG SKIDMORE MA, MA, MDIV, LPC

Provider Business Mailing Address
First Line	:	1554 MACKINAW RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-3349
Country	:	US
Telephone Number	:	616-241-2413
Fax Number	:

Provider Business Practice Location Address
First Line	:	1514 WEALTHY ST SE
Second Line	:	SUITE 260
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-2755
Country	:	US
Telephone Number	:	616-451-3008
Fax Number	:	616-451-3070

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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