Provider Demographics
NPI:1982439931
Name:THE PEDIATRIC CLINIC FOR BEHAVIORAL HEALTH, PLLC
Entity type:Organization
Organization Name:THE PEDIATRIC CLINIC FOR BEHAVIORAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:
Authorized Official - Last Name:RADCLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:331-442-4249
Mailing Address - Street 1:2012 VANDALIA ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4848
Mailing Address - Country:US
Mailing Address - Phone:307-999-6373
Mailing Address - Fax:618-350-0083
Practice Address - Street 1:2012 VANDALIA ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4848
Practice Address - Country:US
Practice Address - Phone:307-999-6373
Practice Address - Fax:618-350-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-07
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty