Provider Demographics
NPI:1144843616
Name:SKOLNICK, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SKOLNICK
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 1:226 GRISWOLD DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1023
Mailing Address - Country:US
Mailing Address - Phone:857-313-9571
Mailing Address - Fax:
Practice Address - Street 1:226 GRISWOLD DR
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1023
Practice Address - Country:US
Practice Address - Phone:857-313-9571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8922363LP0808X
CT169596163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health