Healthcare Provider Details

I. General information

NPI: 1184677619
Provider Name (Legal Business Name): CHILDREN'S CENTER FOR BEHAVIORAL DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 N 88TH ST
EAST SAINT LOUIS IL
62203-2705
US

IV. Provider business mailing address

353 N 88TH ST
EAST SAINT LOUIS IL
62203-2705
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-1152
  • Fax: 618-398-6977
Mailing address:
  • Phone: 618-398-1152
  • Fax: 618-398-6977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number165005001
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101YM0800X
License Number StateIL

VIII. Authorized Official

Name: CAROLYN BIRTH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 618-398-1152