Provider Demographics
NPI:1144707647
Name:SKELTON, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SKELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 N MERIDIAN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4064
Mailing Address - Country:US
Mailing Address - Phone:317-252-5258
Mailing Address - Fax:
Practice Address - Street 1:3921 N MERIDIAN ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4064
Practice Address - Country:US
Practice Address - Phone:317-252-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000594A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health