Provider Demographics
NPI:1689139917
Name:SKIBA, LINA (MA)
Entity Type:Individual
Prefix:MS
First Name:LINA
Middle Name:
Last Name:SKIBA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 EUSTON RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4805
Mailing Address - Country:US
Mailing Address - Phone:718-610-9353
Mailing Address - Fax:
Practice Address - Street 1:THOM CHILD & FAMILY SERVICES
Practice Address - Street 2:555 ARMORY ST
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-383-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77125-SP-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA77125-SP-SLOtherMASSACHUSETTS STATE LICENSURE OF SPEECH & LANGUAGE
14181776OtherASHA