1306039243 NPI number — CHILD & ADOLESCENT TREATMENT CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306039243 NPI number — CHILD & ADOLESCENT TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILD & ADOLESCENT TREATMENT CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KRISSA E KIRBY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306039243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 741240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32774-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-774-5211
Provider Business Mailing Address Fax Number:
386-774-5251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 LEE RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32789-1859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-739-5874
Provider Business Practice Location Address Fax Number:
407-644-1292
Provider Enumeration Date:
08/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOLIDGE
Authorized Official First Name:
ROBERT C
Authorized Official Middle Name:
Authorized Official Title or Position:
AGENT/REPRESENTATIVE
Authorized Official Telephone Number:
386-774-5211

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  PY6399 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 54725 . This is a "FL BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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