Provider Demographics
NPI:1578929568
Name:SKIDMORE-BENNETT, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:SKIDMORE-BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4686 GROOM ROAD SUITE D
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714
Mailing Address - Country:US
Mailing Address - Phone:225-218-4444
Mailing Address - Fax:225-448-3000
Practice Address - Street 1:4686 GROOM RD STE D
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-3067
Practice Address - Country:US
Practice Address - Phone:225-218-4444
Practice Address - Fax:225-448-3000
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health