Provider Demographics
NPI:1508534686
Name:CANTON CHILD AND FAMILY THERAPY CLINIC
Entity Type:Organization
Organization Name:CANTON CHILD AND FAMILY THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/LEAD PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VAMSI
Authorized Official - Middle Name:C
Authorized Official - Last Name:TUMMALACHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:443-300-8255
Mailing Address - Street 1:2700 LIGHTHOUSE PT E STE 270
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4791
Mailing Address - Country:US
Mailing Address - Phone:443-300-8255
Mailing Address - Fax:
Practice Address - Street 1:2700 LIGHTHOUSE PT E STE 270
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4791
Practice Address - Country:US
Practice Address - Phone:443-589-5848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-02
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)