Provider Demographics
NPI:1619213055
Name:CHILDRENS PSYCHIATRIC CENTER OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:CHILDRENS PSYCHIATRIC CENTER OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH ASSOCIATE
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:505-710-1826
Mailing Address - Street 1:2600 MARBLE AVE NE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2058
Mailing Address - Country:US
Mailing Address - Phone:505-272-2190
Mailing Address - Fax:505-272-3466
Practice Address - Street 1:2600 MARBLE AVE NE BLDG 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2058
Practice Address - Country:US
Practice Address - Phone:505-272-2190
Practice Address - Fax:505-272-3466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health