Healthcare Provider Details

I. General information

NPI: 1801959432
Provider Name (Legal Business Name): DEMETRA CHILDRESS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 06/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 JUAN TABO BLVD NE SUITE 103
ALBUQUERQUE NM
87111-2681
US

IV. Provider business mailing address

4425 JUAN TABO BLVD NE SUITE 103
ALBUQUERQUE NM
87111-2681
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-8908
  • Fax: 505-292-3109
Mailing address:
  • Phone: 505-292-8908
  • Fax: 505-292-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0975
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: