Basic Information
| Provider Information | |||||||||
| NPI: | 1538150388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR FAMILY DEVELOPMENT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1258 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413428437 | ||||||||
| FaxNumber: | 5413421639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1258 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413428437 | ||||||||
| FaxNumber: | 5413421639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2005 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | RIOS | ||||||||
| AuthorizedOfficialFirstName: | SHANTI | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5413428437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 170157 | 05 | OR | MEDICAID | 037098 | 05 | OR | MEDICAID |