Provider Demographics
NPI:1891092128
Name:SKODA, MICHAEL J (LPCC-S, LICDC, SAP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:SKODA
Suffix:
Gender:M
Credentials:LPCC-S, LICDC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26777 LORAIN RD STE 403
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3224
Mailing Address - Country:US
Mailing Address - Phone:440-220-6926
Mailing Address - Fax:440-220-7750
Practice Address - Street 1:26777 LORAIN RD STE 403
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070
Practice Address - Country:US
Practice Address - Phone:440-220-6926
Practice Address - Fax:440-220-7750
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.141063101YA0400X
OHE.1000455-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0206683Medicaid