Provider Demographics
NPI:1639902075
Name:CODY SKOWRONSKI, KELSEY (LAC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:CODY SKOWRONSKI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3963 W CAMINO DEL RIO
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-5526
Mailing Address - Country:US
Mailing Address - Phone:928-219-0865
Mailing Address - Fax:
Practice Address - Street 1:5320 N 16TH ST STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3241
Practice Address - Country:US
Practice Address - Phone:602-456-2835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22065101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor