Provider Demographics
NPI:1124187323
Name:CHILDREN'S PROGRAM
Entity Type:Organization
Organization Name:CHILDREN'S PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RANIK
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:503-452-8002
Mailing Address - Street 1:7707 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2458
Mailing Address - Country:US
Mailing Address - Phone:503-452-8002
Mailing Address - Fax:
Practice Address - Street 1:7707 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2458
Practice Address - Country:US
Practice Address - Phone:503-452-8002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YP2500X, 103TC0700X, 103TC2200X, 2080P0006X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Not Answered2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty