Provider Demographics
NPI:1073804092
Name:WILD LILAC CHILD DEVELOPMENT COMMUNITY
Entity Type:Organization
Organization Name:WILD LILAC CHILD DEVELOPMENT COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:STATMAN-WEIL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:503-236-3240
Mailing Address - Street 1:1533 SE 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1533 SE 32ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5008
Practice Address - Country:US
Practice Address - Phone:503-236-3240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health