Basic Information
| Provider Information | |||||||||
| NPI: | 1376630244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKURKA | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 FRANCIS AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028601506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017231942 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 JOHN A CUMMINGS WAY | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028953247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDP00041 | RI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | PC206 | RI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | CP00408220 | 01 | RI | BLUE CHIP | OTHER | 0000069520 | 01 | RI | BLUE CROSS | OTHER | AS32737 | 05 | RI | MEDICAID |