Provider Demographics
NPI:1184677619
Name:CHILDREN'S CENTER FOR BEHAVIORAL DEVELOPMENT
Entity Type:Organization
Organization Name:CHILDREN'S CENTER FOR BEHAVIORAL DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-398-1152
Mailing Address - Street 1:353 N 88TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-2705
Mailing Address - Country:US
Mailing Address - Phone:618-398-1152
Mailing Address - Fax:618-398-6977
Practice Address - Street 1:353 N 88TH ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-2705
Practice Address - Country:US
Practice Address - Phone:618-398-1152
Practice Address - Fax:618-398-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL165005001101Y00000X
IL101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty