Provider Demographics
NPI:1144275777
Name:CHILD & ADOLESCENT CLINIC, PS
Entity type:Organization
Organization Name:CHILD & ADOLESCENT CLINIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-577-1771
Mailing Address - Street 1:971 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2503
Mailing Address - Country:US
Mailing Address - Phone:360-577-1771
Mailing Address - Fax:360-423-1405
Practice Address - Street 1:971 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-577-1771
Practice Address - Fax:360-423-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7066202Medicaid