Provider Demographics
NPI:1730599382
Name:WEST TEXAS CHILD DEVELOPMENT CENTER
Entity type:Organization
Organization Name:WEST TEXAS CHILD DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENR
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA
Authorized Official - Phone:325-320-3204
Mailing Address - Street 1:2032 W HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3806
Mailing Address - Country:US
Mailing Address - Phone:325-320-3204
Mailing Address - Fax:
Practice Address - Street 1:2032 W HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3806
Practice Address - Country:US
Practice Address - Phone:325-320-3204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
TX1-13-14897251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health