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General NPI Number Information
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NPI Number | 1306039243
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Entity Type | Organization
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Legal Business Name | CHILD & ADOLESCENT TREATMENT CENTER
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Dates
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Enumeration Date | 08/23/2007
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1950 LEE RD SUITE 202
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City | WINTER PARK
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State | FL
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Zip | 32789-1859
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Country | US
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Telephone | 407-739-5874
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Fax | 407-644-1292
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Provider Business Mailing Address
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Address Line | PO BOX 741240
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City | ORANGE CITY
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State | FL
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Zip | 32774-1240
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Country | US
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Telephone | 386-774-5211
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Fax | 386-774-5251
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Authorized Official
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Title or Position | AGENT/REPRESENTATIVE
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Name | MR. ROBERT C COOLIDGE
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Credential |
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Telephone | 386-774-5211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PY6399
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License Number State | FL
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