Provider Demographics
NPI:1811095730
Name:SKIDMORE, KORI LEVOS (PHD)
Entity type:Individual
Prefix:DR
First Name:KORI
Middle Name:LEVOS
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 LAKE ST
Mailing Address - Street 2:SUITE #201
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1424
Mailing Address - Country:US
Mailing Address - Phone:312-371-1157
Mailing Address - Fax:708-848-4436
Practice Address - Street 1:720 LAKE ST
Practice Address - Street 2:SUITE #201
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1424
Practice Address - Country:US
Practice Address - Phone:312-371-1157
Practice Address - Fax:708-848-4436
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71-5445103TC0700X, 103T00000X
IL103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1632112Medicare UPIN