Provider Demographics
NPI:1467129353
Name:SKODACK, KRISTA (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:SKODACK
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51145 NICOLETTE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-4585
Mailing Address - Country:US
Mailing Address - Phone:586-228-9991
Mailing Address - Fax:
Practice Address - Street 1:6555 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2713
Practice Address - Country:US
Practice Address - Phone:586-243-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001650103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst