Provider Demographics
NPI:1548705064
Name:CHILDERS PROFESSIONAL SERVICE LLC
Entity type:Organization
Organization Name:CHILDERS PROFESSIONAL SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-383-7531
Mailing Address - Street 1:PO BOX738
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029
Mailing Address - Country:US
Mailing Address - Phone:315-383-7531
Mailing Address - Fax:315-676-0014
Practice Address - Street 1:27 JOSHUA LN
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-2176
Practice Address - Country:US
Practice Address - Phone:315-383-7531
Practice Address - Fax:315-676-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05740611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02426997Medicaid