Provider Demographics
NPI:1396815049
Name:SKIDMORE, RICK WADE (LISW)
Entity Type:Individual
Prefix:MR
First Name:RICK
Middle Name:WADE
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-2814
Mailing Address - Country:US
Mailing Address - Phone:419-407-5100
Mailing Address - Fax:419-885-0203
Practice Address - Street 1:4651 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43611-2814
Practice Address - Country:US
Practice Address - Phone:419-407-5100
Practice Address - Fax:419-885-0203
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI - 00084861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH25591Medicare PIN
P66336Medicare UPIN