Provider Demographics
NPI:1356064810
Name:SKOLNICK, SHERIDAN SHAE
Entity type:Individual
Prefix:
First Name:SHERIDAN
Middle Name:SHAE
Last Name:SKOLNICK
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 1:7902 AVENIDA NAVIDAD APT 160
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5454
Mailing Address - Country:US
Mailing Address - Phone:858-444-7724
Mailing Address - Fax:
Practice Address - Street 1:1122 BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5629
Practice Address - Country:US
Practice Address - Phone:858-444-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis