Provider Demographics
NPI:1265450886
Name:SKELTON, ANDREA L (LSCSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:SKELTON
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:L
Other - Last Name:PENNOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1333 N BROADWAY AVE STE E
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2894
Mailing Address - Country:US
Mailing Address - Phone:316-201-1676
Mailing Address - Fax:316-201-1762
Practice Address - Street 1:1333 N BROADWAY AVE
Practice Address - Street 2:SUITE E
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2894
Practice Address - Country:US
Practice Address - Phone:316-201-1676
Practice Address - Fax:316-201-1762
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS198101YA0400X
KS39101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200654090CMedicaid