Provider Demographics
NPI:1699396671
Name:SKINNER, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:SKINNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E ARLINGTON BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5019
Mailing Address - Country:US
Mailing Address - Phone:252-695-0269
Mailing Address - Fax:
Practice Address - Street 1:150 E ARLINGTON BLVD STE E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5019
Practice Address - Country:US
Practice Address - Phone:252-695-0269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23512101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)