Provider Demographics
NPI:1639868169
Name:SKILLZ BOUTIQUE
Entity Type:Organization
Organization Name:SKILLZ BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:248-924-9644
Mailing Address - Street 1:25430 SOUTHFIELD RD APT 102
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1957
Mailing Address - Country:US
Mailing Address - Phone:248-924-9644
Mailing Address - Fax:
Practice Address - Street 1:25430 SOUTHFIELD RD APT 102
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1957
Practice Address - Country:US
Practice Address - Phone:248-924-9644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-02
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty