Provider Demographics
NPI:1467576041
Name:CHILD STUDY CLINIC
Entity Type:Organization
Organization Name:CHILD STUDY CLINIC
Other - Org Name:S.T.A.R.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC COORDINATOR I
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-575-0681
Mailing Address - Street 1:PO BOX 5140
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-5140
Mailing Address - Country:US
Mailing Address - Phone:361-575-0681
Mailing Address - Fax:361-575-0100
Practice Address - Street 1:4208 RETAMA CIR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2765
Practice Address - Country:US
Practice Address - Phone:361-575-0681
Practice Address - Fax:361-575-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618622163WC0400X
TX649214163WC0400X
TXG6459171M00000X, 174H00000X, 2080N0001X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126856702Medicaid