1780152603 NPI number — MOLLY C SKINNER LPC-IT AND SAC-IT

Table of content: MOLLY C SKINNER LPC-IT AND SAC-IT (NPI 1780152603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780152603 NPI number — MOLLY C SKINNER LPC-IT AND SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKINNER
Provider First Name:
MOLLY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC-IT AND SAC-IT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780152603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1707 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CROSSE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54601-4200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-785-0001
Provider Business Mailing Address Fax Number:
608-785-0002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 W WISCONSIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54656-2233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-269-1588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  4177-226 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 16422 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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