Provider Demographics
NPI:1891114435
Name:SKINNER, LAURA S
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:S
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 1:11520 N PORT WASHINGTON RD STE 101B
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3432
Mailing Address - Country:US
Mailing Address - Phone:262-365-9825
Mailing Address - Fax:
Practice Address - Street 1:124 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1901
Practice Address - Country:US
Practice Address - Phone:262-365-9825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5323-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5323-125OtherSTATE LICENSE, WI