Provider Demographics
NPI:1710192653
Name:SKELLEY, VIVIAN FAYE (CDS)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:FAYE
Last Name:SKELLEY
Suffix:
Gender:F
Credentials:CDS
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:FAYE
Other - Last Name:WINCHESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 KICKAPOO VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-8086
Mailing Address - Country:US
Mailing Address - Phone:217-821-1752
Mailing Address - Fax:217-345-0910
Practice Address - Street 1:7704 DEERPATH RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-8735
Practice Address - Country:US
Practice Address - Phone:217-508-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist