Provider Demographics
NPI:1790919835
Name:SKONICKI, ELIZABETH ANNE (COTA/L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:SKONICKI
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9630 MILESTONE WAY
Mailing Address - Street 2:APT 4104
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-4285
Mailing Address - Country:US
Mailing Address - Phone:815-546-8527
Mailing Address - Fax:
Practice Address - Street 1:1415 ROUTE 70 E
Practice Address - Street 2:SUITE 103
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2210
Practice Address - Country:US
Practice Address - Phone:800-670-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01693224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant