Provider Demographics
NPI:1780152603
Name:SKINNER, MOLLY C (LPC-IT AND SAC-IT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:C
Last Name:SKINNER
Suffix:
Gender:F
Credentials:LPC-IT AND SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4200
Mailing Address - Country:US
Mailing Address - Phone:608-785-0001
Mailing Address - Fax:608-785-0002
Practice Address - Street 1:1111 W WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2233
Practice Address - Country:US
Practice Address - Phone:608-269-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4177-226101YM0800X
WI16422101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health