Provider Demographics
NPI:1538723127
Name:CHILDRESS, DARLENE
Entity type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3008
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3008
Mailing Address - Country:US
Mailing Address - Phone:618-734-4400
Mailing Address - Fax:618-477-8557
Practice Address - Street 1:13245 KESSLER RD
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-3101
Practice Address - Country:US
Practice Address - Phone:618-734-4400
Practice Address - Fax:618-477-8557
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL27891OtherILLINOIS CERTIFICATION BOARD