Provider Demographics
NPI:1134605983
Name:CHILD AND ADOLESCENT THERAPY
Entity type:Organization
Organization Name:CHILD AND ADOLESCENT THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:SANBORN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:216-551-7595
Mailing Address - Street 1:20588 LORAIN RD APT 14
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3466
Mailing Address - Country:US
Mailing Address - Phone:216-551-7595
Mailing Address - Fax:
Practice Address - Street 1:30400 DETROIT RD STE 301
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1855
Practice Address - Country:US
Practice Address - Phone:216-551-7595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1302314-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222497Medicaid