Healthcare Provider Details

I. General information

NPI: 1063894376
Provider Name (Legal Business Name): DENISE CHILDRESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 S DIVISION ST SUITE C & D
GUTHRIE OK
73044-6027
US

IV. Provider business mailing address

PO BOX 12978
OKLAHOMA CITY OK
73157-2978
US

V. Phone/Fax

Practice location:
  • Phone: 405-260-3441
  • Fax: 405-260-3442
Mailing address:
  • Phone: 405-858-2700
  • Fax: 405-858-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1240
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: