Provider Demographics
NPI:1255002572
Name:SKIDMORE, BRANDON D (LCDC-I)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:D
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 LONDONDERRY LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7792
Mailing Address - Country:US
Mailing Address - Phone:940-483-0644
Mailing Address - Fax:
Practice Address - Street 1:621 LONDONDERRY LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-7792
Practice Address - Country:US
Practice Address - Phone:940-483-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56623101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)