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General NPI Number Information
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NPI Number | 1457304834
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Entity Type | Individual
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Provider Name | TOMMY KENNETH CHILDERS PHD, LMHC
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Gender | Male
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Dates
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Enumeration Date | 05/18/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3948 SUNBEAM RD
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City | JACKSONVILLE
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State | FL
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Zip | 32257-8852
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Country | US
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Telephone | 904-886-9286
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Fax | 904-886-9669
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Provider Business Mailing Address
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Address Line | 3612 CAMERON CROSSING DR.
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City | JACKSONVILLE
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State | FL
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Zip | 32223
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Country | US
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Telephone | 904-886-9335
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Fax | 904-886-9669
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH0001911
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License Number State | FL
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