Basic Information
| Provider Information | |||||||||
| NPI: | 1730317033 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILD & ADOLESCENT RESOURCE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1736 NE HEMBREE ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971283314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034722233 | ||||||||
| FaxNumber: | 5034722299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1736 NE HEMBREE ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971283314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034722233 | ||||||||
| FaxNumber: | 5034722299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | FELLOWS | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5034722233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW, CADC I | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 08-12-12 | OR | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | L4459 | OR | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.