Provider Demographics
NPI:1255796520
Name:SKINNER, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
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 1:414 W PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CHURUBUSCO
Mailing Address - State:IN
Mailing Address - Zip Code:46723-2104
Mailing Address - Country:US
Mailing Address - Phone:260-452-0553
Mailing Address - Fax:
Practice Address - Street 1:414 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CHURUBUSCO
Practice Address - State:IN
Practice Address - Zip Code:46723-2104
Practice Address - Country:US
Practice Address - Phone:260-452-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst