Provider Demographics
NPI:1629787338
Name:SKEETER, PHYLLIS LATRICE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:PHYLLIS
Middle Name:LATRICE
Last Name:SKEETER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1121 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-4175
Mailing Address - Country:US
Mailing Address - Phone:757-237-1142
Mailing Address - Fax:
Practice Address - Street 1:1121 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-4175
Practice Address - Country:US
Practice Address - Phone:757-237-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000000Medicaid