Provider Demographics
NPI:1700154713
Name:COMMONWEALTH CENTER FOR CHILDREN AND ADOLESCENTS
Entity Type:Organization
Organization Name:COMMONWEALTH CENTER FOR CHILDREN AND ADOLESCENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:CRICKENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:PMH-NP
Authorized Official - Phone:540-332-2142
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24402-4000
Mailing Address - Country:US
Mailing Address - Phone:540-332-2142
Mailing Address - Fax:540-332-2209
Practice Address - Street 1:1355 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-9146
Practice Address - Country:US
Practice Address - Phone:540-332-2142
Practice Address - Fax:540-332-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017139232273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit