Provider Demographics
NPI:1467486324
Name:SKILES, ANGELINA MICHELLE (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:MS
First Name:ANGELINA
Middle Name:MICHELLE
Last Name:SKILES
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:MRS
Other - First Name:ANGELINA
Other - Middle Name:MICHELLE
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICENSED CLINICAL SO
Mailing Address - Street 1:118 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-5501
Mailing Address - Country:US
Mailing Address - Phone:423-979-2825
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF WEST MARKET AND LAMONT STREET
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-979-2675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000046801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000004680OtherCMSW