Provider Demographics
| NPI: | 1013421031 |
|---|---|
| Name: | CENTER FOR CHILD DEVELOPMENT AND FAMILY EDUCATION |
| Entity Type: | Organization |
| Organization Name: | CENTER FOR CHILD DEVELOPMENT AND FAMILY EDUCATION |
| Other - Org Name: | CENTER FOR CHILD DEVELOPMENT & FAMILY ED VB |
| Other - Org Type: | Other Name |
| Authorized Official - Title/Position: | OFFICE ADMINISTRATION |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | MARY |
| Authorized Official - Middle Name: | E |
| Authorized Official - Last Name: | KNIGHT |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 479-430-7603 |
| Mailing Address - Street 1: | 2010 CHESTNUT ST STE H |
| Mailing Address - Street 2: | |
| Mailing Address - City: | VAN BUREN |
| Mailing Address - State: | AR |
| Mailing Address - Zip Code: | 72956-5340 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 479-430-7603 |
| Mailing Address - Fax: | 479-430-7596 |
| Practice Address - Street 1: | 2010 CHESTNUT ST STE H |
| Practice Address - Street 2: | |
| Practice Address - City: | VAN BUREN |
| Practice Address - State: | AR |
| Practice Address - Zip Code: | 72956-5340 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 479-430-7603 |
| Practice Address - Fax: | 479-430-7596 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | CENTER FOR CHILD DEVELOPMENT AND FAMILY EDUCATION |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2017-11-29 |
| Last Update Date: | 2020-08-13 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 224Z00000X, 225100000X, 225200000X, 225X00000X, 2355S0801X, 235Z00000X, 261QP2000X | ||
| AR | 30293 | 261Q00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | Group - Multi-Specialty | |
| No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 2355S0801X | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | Group - Multi-Specialty |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
| No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| AR | 222348724 | Medicaid | |
| AR | 225888742 | Medicaid |
