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General NPI Number Information
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NPI Number | 1548705064
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Entity Type | Organization
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Legal Business Name | CHILDERS PROFESSIONAL SERVICE LLC
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Dates
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Enumeration Date | 12/20/2016
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Last Update Date | 12/20/2016
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Provider Practice Location Address
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Address Line | 27 JOSHUA LN
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City | CENTRAL SQUARE
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State | NY
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Zip | 13036-2176
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Country | US
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Telephone | 315-383-7531
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Fax | 315-676-0014
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Provider Business Mailing Address
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Address Line | PO BOX738
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City | BREWERTON
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State | NY
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Zip | 13029
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Country | US
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Telephone | 315-383-7531
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Fax | 315-676-0014
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Authorized Official
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Title or Position | DIRECTOR
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Name | DANIEL JOSEPH CHILDERS
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Credential | LCSW-R
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Telephone | 315-383-7531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0574061
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License Number State | NY
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