Basic Information
| Provider Information | |||||||||
| NPI: | 1235530726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKYLSEN | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4160 JOHN R ST STE 615 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454195 | ||||||||
| FaxNumber: | 3139938669 | ||||||||
| Practice Location | |||||||||
| Address1: | 4160 JOHN R ST STE 615 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454195 | ||||||||
| FaxNumber: | 3139938669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2014 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.