Basic Information
| Provider Information | |||||||||
| NPI: | 1164618286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKRDLANT | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS, CCDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122770809 | ||||||||
| FaxNumber: | 7122551120 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122770809 | ||||||||
| FaxNumber: | 7122551120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 09/21/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 07003 | IA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0791665 | 05 | IA | MEDICAID |