Provider Demographics
NPI:1699907832
Name:CHILDRENS DIAGNOSTIC & TREATMENT CENTER INC
Entity type:Organization
Organization Name:CHILDRENS DIAGNOSTIC & TREATMENT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON-RANDAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-728-1060
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-728-8080
Mailing Address - Fax:954-779-1957
Practice Address - Street 1:1401 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2619
Practice Address - Country:US
Practice Address - Phone:954-728-8080
Practice Address - Fax:954-779-1957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34478OtherBCBS
FL006458400Medicaid
FL34478OtherBCBS