=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174853717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND INSTITUTE FOR TRAUMA RECOVERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2010
-----------------------------------------------------
Last Update Date | 12/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 199 MAIN ST
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-571-3008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1189
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-1189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-229-2398
-----------------------------------------------------
Fax | 207-571-3263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MR. RUDOLPH ALBERT SKOWRONSKI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 207-571-3008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------