Provider Demographics
NPI:1790561736
Name:SKINNER, DEVYN
Entity Type:Individual
Prefix:
First Name:DEVYN
Middle Name:
Last Name:SKINNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 RYEGRASS WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:45431-6426
Mailing Address - Country:US
Mailing Address - Phone:616-403-6042
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-6877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.110171104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker