Healthcare Provider Details

I. General information

NPI: 1124187323
Provider Name (Legal Business Name): CHILDREN'S PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7707 SW CAPITOL HWY
PORTLAND OR
97219-2458
US

IV. Provider business mailing address

7707 SW CAPITOL HWY
PORTLAND OR
97219-2458
US

V. Phone/Fax

Practice location:
  • Phone: 503-452-8002
  • Fax:
Mailing address:
  • Phone: 503-452-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number StateOR

VIII. Authorized Official

Name: MINDY J RANIK
Title or Position: CLINIC COORDINATOR
Credential: M.S.
Phone: 503-452-8002