Provider Demographics
NPI:1386218048
Name:INTENSIVE TRAUMA RECOVERY LLC
Entity Type:Organization
Organization Name:INTENSIVE TRAUMA RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-230-2310
Mailing Address - Street 1:364 PATTESON DR # 105
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3202
Mailing Address - Country:US
Mailing Address - Phone:773-230-2310
Mailing Address - Fax:
Practice Address - Street 1:1102 ABOUT TOWN PLACE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508
Practice Address - Country:US
Practice Address - Phone:800-755-6105
Practice Address - Fax:800-755-6105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)