Adolescent & Child Development Center, LLC
Organization Active NPI Developmental Disabilities Clinic/Center · Pocatello, ID
NPI 1063671469 · NPPES record last updated Apr 2, 2009
Key facts
- NPI
- 1063671469
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Developmental Disabilities Clinic/Center 261QD1600X
- License
- 261QD1600X (ID)
- Legal business name
- ADOLESCENT & CHILD DEVELOPMENT CENTER, LLC
- Practice address
- 151 N 3Rd Ave
Suite 110
Pocatello, ID 83201-6331 - Phone
- (208) 232-5622
- Fax
- (208) 233-4639
- NPI assigned
- Jun 2, 2008
- Organization subpart
- No
Authorized official
- Name
- Mr. Vance Ray Walker
- Title
- Owner/Executive Director
- Phone
- (208) 232-5622
Practitioners 1
-
Teresa Rae Walker, LMSW
National Provider Directory
Locations
151 N 3rd Ave
Ste 110
Pocatello, ID 83201
Phone (208) 232-5622
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Developmental Disabilities Clinic/Center | 261QD1600X | 261QD1600X | ID | Yes |
| Mental Health Clinic/Center (Including Community Mental Health Center) | 261QM0801X | 261QM0801X | ID | |
| Adult Mental Health Clinic/Center | 261QM0850X | 261QM0850X | ID |
Addresses
Primary practice location
151 N 3Rd Ave
Suite 110
Pocatello, ID 83201-6331
Mailing address
151 N 3Rd Ave
Suite 110
Pocatello, ID 83201-6331
Phone (208) 232-5622
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 808259000 | Medicaid | ID | |
| 808257100 | Medicaid | ID | |
| 808028200 | Medicaid | ID |
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All providers in Pocatello, ID · Developmental Disabilities Clinic/Center in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 2, 2009. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.