Provider Demographics
NPI:1629152327
Name:COLUMBIA COUNTY CHILD ABUSE ASSESSMENT CENTER
Entity Type:Organization
Organization Name:COLUMBIA COUNTY CHILD ABUSE ASSESSMENT CENTER
Other - Org Name:AMANI CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GALOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-366-4005
Mailing Address - Street 1:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-8001
Mailing Address - Country:US
Mailing Address - Phone:503-366-4005
Mailing Address - Fax:503-366-0314
Practice Address - Street 1:1621 COLUMBIA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6221
Practice Address - Country:US
Practice Address - Phone:503-366-4005
Practice Address - Fax:503-366-0314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226810Medicaid