Provider Demographics
NPI:1407932270
Name:SKOLNIK, MIRI ELANA (PSYD)
Entity Type:Individual
Prefix:
First Name:MIRI
Middle Name:ELANA
Last Name:SKOLNIK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MIRI
Other - Middle Name:ELANA
Other - Last Name:SKOLNIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:76 CAROLINA AVE
Mailing Address - Street 2:APT.1
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3205
Mailing Address - Country:US
Mailing Address - Phone:617-971-0432
Mailing Address - Fax:
Practice Address - Street 1:859 WILLARD ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7482
Practice Address - Country:US
Practice Address - Phone:617-774-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7868103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50963Medicare ID - Type Unspecified