Provider Demographics
NPI:1104181395
Name:SKIDMORE, BREANNE NICKOLE (LSW)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:NICKOLE
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 RUNAWAY BAY DR
Mailing Address - Street 2:APT. 1B
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-4811
Mailing Address - Country:US
Mailing Address - Phone:440-313-5029
Mailing Address - Fax:
Practice Address - Street 1:1490 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2140
Practice Address - Country:US
Practice Address - Phone:614-252-0731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 11008751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical