Provider Demographics
NPI:1942219126
Name:SKOLNIKOFF, IVAN (MA)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:SKOLNIKOFF
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WILDWOOD PL
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-2049
Mailing Address - Country:US
Mailing Address - Phone:510-502-7554
Mailing Address - Fax:
Practice Address - Street 1:2127 ASHBY AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1884
Practice Address - Country:US
Practice Address - Phone:510-496-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35832106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist