Basic Information
| Provider Information | |||||||||
| NPI: | 1053343558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH FOR CHILDREN, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CHILD CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3995 MARCOLA RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417261465 | ||||||||
| FaxNumber: | 5417255085 | ||||||||
| Practice Location | |||||||||
| Address1: | 3995 MARCOLA RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417261465 | ||||||||
| FaxNumber: | 5417255085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELLARD | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5417261465 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | THE CHILD CENTER | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 033142 | 05 | OR | MEDICAID |