Healthcare Provider Details

I. General information

NPI: 1144648379
Provider Name (Legal Business Name): ROBERT CHILDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 MULBERRY ST.
ELIZABETH WV
26143-0189
US

IV. Provider business mailing address

1 MULBERRY ST
ELIZABETH WV
26143-0189
US

V. Phone/Fax

Practice location:
  • Phone: 304-485-6513
  • Fax:
Mailing address:
  • Phone: 304-485-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number22055
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: