Provider Demographics
NPI:1851697635
Name:SKIDMORE, TERRANCE JOSEPH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:JOSEPH
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37161 AUDUBON PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GEISMAR
Mailing Address - State:LA
Mailing Address - Zip Code:70734-3265
Mailing Address - Country:US
Mailing Address - Phone:337-853-2292
Mailing Address - Fax:225-313-3563
Practice Address - Street 1:1600 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3603
Practice Address - Country:US
Practice Address - Phone:228-865-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA88421041C0700X
MSC87641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical