Provider Demographics
NPI:1992949796
Name:KLAMATH CHILD AND FAMILY TREATMENT CENTER
Entity type:Organization
Organization Name:KLAMATH CHILD AND FAMILY TREATMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDALENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-883-1030
Mailing Address - Street 1:2210 N ELDORADO
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6418
Mailing Address - Country:US
Mailing Address - Phone:541-883-1030
Mailing Address - Fax:541-884-2338
Practice Address - Street 1:725 WASHBURN WAY
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-3648
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:541-884-2338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KLAMATH MENTAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-23
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500500017Medicaid