Provider Demographics
NPI:1336990563
Name:SKIDMORE, SAMUEL (MS)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4056 S SUADA CIR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2222 BANCROFT WAY SPC 4300
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4300
Practice Address - Country:US
Practice Address - Phone:510-642-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health