MEDICARE: KIANTE KARIN CHILDRESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1457828667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIANTE KARIN CHILDRESS

Provider Business Mailing Address
First Line	:	3871 REDWINE RD APT 7304
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344-5879
Country	:	US
Telephone Number	:	770-570-0101
Fax Number	:

Provider Business Practice Location Address
First Line	:	3871 REDWINE RD APT 7304
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344-5879
Country	:	US
Telephone Number	:	770-570-0101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2018
Last Update Date	:	10/25/2018

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