Provider Demographics
NPI:1699117085
Name:SKOCZYLAS, REBECCA (EDS)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:SKOCZYLAS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22650 SHEVINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-6213
Mailing Address - Country:US
Mailing Address - Phone:404-849-8521
Mailing Address - Fax:
Practice Address - Street 1:136 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2324
Practice Address - Country:US
Practice Address - Phone:404-849-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool