Provider Demographics
NPI:1679161293
Name:SKANES, STEPHANIE DELORIS
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DELORIS
Last Name:SKANES
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 1:3876 RENEE DR UNIT C
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4108
Mailing Address - Country:US
Mailing Address - Phone:843-504-8346
Mailing Address - Fax:
Practice Address - Street 1:1421 S POTOMAC ST STE 110
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4511
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC109171041C0700X
COCSW.099284571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCSW.09928457OtherDORA
10917OtherLICENSED INDEPENDENT CLINICAL SOCIAL WORKER