Provider Demographics
NPI:1972089258
Name:SKIDMORE, MARIANNA R (LPC)
Entity Type:Individual
Prefix:
First Name:MARIANNA
Middle Name:R
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:34084 WILDERNESS RD
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:VA
Practice Address - Zip Code:24263-7899
Practice Address - Country:US
Practice Address - Phone:276-346-3590
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007761101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional