Provider Demographics
NPI:1720558604
Name:ROBERT SKIDMORE PHD LLC
Entity Type:Organization
Organization Name:ROBERT SKIDMORE PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SKIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:541-500-8655
Mailing Address - Street 1:PO BOX 4752
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0197
Mailing Address - Country:US
Mailing Address - Phone:541-500-8655
Mailing Address - Fax:800-433-1396
Practice Address - Street 1:18 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7309
Practice Address - Country:US
Practice Address - Phone:541-500-8655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500722503Medicaid