Provider Demographics
NPI:1154814515
Name:SKINNER, GIOVANTE DERICK
Entity Type:Individual
Prefix:MR
First Name:GIOVANTE
Middle Name:DERICK
Last Name:SKINNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GIOVANTE
Other - Middle Name:DERICK
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 VILLAGE SQ STE 210
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1624
Mailing Address - Country:US
Mailing Address - Phone:866-565-7222
Mailing Address - Fax:877-734-9114
Practice Address - Street 1:1800 ALEXANDER BELL DR STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-4385
Practice Address - Country:US
Practice Address - Phone:571-495-1673
Practice Address - Fax:877-734-1914
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-22-231311106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician