Provider Demographics
NPI:1275921033
Name:SKIDMORE, KEVIN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43211 DALCOMA DR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6309
Mailing Address - Country:US
Mailing Address - Phone:586-421-4513
Mailing Address - Fax:586-948-8416
Practice Address - Street 1:43211 DALCOMA DR
Practice Address - Street 2:SUITE 7
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6309
Practice Address - Country:US
Practice Address - Phone:586-421-4513
Practice Address - Fax:586-948-8416
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010776441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801077644OtherSTATE OF MICHIGAN LMSW LICENSE