Provider Demographics
NPI:1902830524
Name:KLAMATH CHILD AND FAMILY TREATMENT CENTER
Entity Type:Organization
Organization Name:KLAMATH CHILD AND FAMILY TREATMENT CENTER
Other - Org Name:KLAMATH YOUTH DEVELOPMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMFT
Authorized Official - Phone:541-883-1030
Mailing Address - Street 1:2210 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6418
Mailing Address - Country:US
Mailing Address - Phone:541-883-1030
Mailing Address - Fax:541-884-2338
Practice Address - Street 1:2210 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6418
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:541-884-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223354Medicaid