Provider Demographics
NPI:1306039243
Name:CHILD & ADOLESCENT TREATMENT CENTER
Entity Type:Organization
Organization Name:CHILD & ADOLESCENT TREATMENT CENTER
Other - Org Name:KRISSA E KIRBY
Other - Org Type:Other Name
Authorized Official - Title/Position:AGENT/REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT C
Authorized Official - Middle Name:
Authorized Official - Last Name:COOLIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-5211
Mailing Address - Street 1:PO BOX 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-774-5211
Mailing Address - Fax:386-774-5251
Practice Address - Street 1:1950 LEE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1859
Practice Address - Country:US
Practice Address - Phone:407-739-5874
Practice Address - Fax:407-644-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6399103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54725OtherFL BLUE SHIELD
FL54725OtherFL BLUE SHIELD