Provider Demographics
NPI:1992081137
Name:SKIDMORE, EDWARD CLYDE JR (RSS)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CLYDE
Last Name:SKIDMORE
Suffix:JR
Gender:M
Credentials:RSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1327
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1327
Mailing Address - Country:US
Mailing Address - Phone:580-319-8402
Mailing Address - Fax:
Practice Address - Street 1:417 COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1732
Practice Address - Country:US
Practice Address - Phone:580-319-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral