Provider Demographics
NPI:1235684986
Name:SKODACK, NICOLE R (CTRS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:SKODACK
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2576
Mailing Address - Country:US
Mailing Address - Phone:616-540-4911
Mailing Address - Fax:
Practice Address - Street 1:1719 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2576
Practice Address - Country:US
Practice Address - Phone:616-540-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist