Healthcare Provider Details

I. General information

NPI: 1275551673
Provider Name (Legal Business Name): JOHN FREDERICK CHILDRESS III PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 WESTWOOD OFFICE PARK
FREDERICKSBURG VA
22401-5121
US

IV. Provider business mailing address

174 HUNTING GREEN LN
KENTS STORE VA
23084-2284
US

V. Phone/Fax

Practice location:
  • Phone: 540-899-4025
  • Fax: 540-374-3313
Mailing address:
  • Phone: 434-591-1163
  • Fax: 540-374-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810002716
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0810002716
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number0810002716
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: