MEDICARE: CHILDERS PROFESSIONAL SERVICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0574061	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548705064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDERS PROFESSIONAL SERVICE LLC

Provider Business Mailing Address
First Line	:	PO BOX738
Second Line	:
City	:	BREWERTON
State	:	NY
Zip	:	13029
Country	:	US
Telephone Number	:	315-383-7531
Fax Number	:	315-676-0014

Provider Business Practice Location Address
First Line	:	27 JOSHUA LN
Second Line	:
City	:	CENTRAL SQUARE
State	:	NY
Zip	:	13036-2176
Country	:	US
Telephone Number	:	315-383-7531
Fax Number	:	315-676-0014

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DANIEL JOSEPH CHILDERS
Credential	:	LCSW-R
Telephone Number	:	315-383-7531

Provider Enumeration Date	:	12/20/2016
Last Update Date	:	12/20/2016

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