Provider Demographics
NPI:1760533632
Name:SKIDMORE, CECILIA MAE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:MAE
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 MACKINAW RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3349
Mailing Address - Country:US
Mailing Address - Phone:616-241-2413
Mailing Address - Fax:
Practice Address - Street 1:1514 WEALTHY ST SE
Practice Address - Street 2:SUITE 260
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2755
Practice Address - Country:US
Practice Address - Phone:616-451-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001787101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401001767OtherCOUNSELOR LICENSE