Healthcare Provider Details

I. General information

NPI: 1205833449
Provider Name (Legal Business Name): JAMES K CHILDERSTON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 SUNSHINE PEAK DR
LOVELAND CO
80538-7217
US

IV. Provider business mailing address

1910 SUNSHINE PEAK DR
LOVELAND CO
80538-7217
US

V. Phone/Fax

Practice location:
  • Phone: 301-991-1018
  • Fax:
Mailing address:
  • Phone: 301-991-1018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY0005723
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY0005723
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY0005723
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY0005723
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: