Provider Demographics
NPI:1366561896
Name:CHILDRESS, JANICE M (MED, LPC, LBSW)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:M
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:MED, LPC, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77803-3985
Mailing Address - Country:US
Mailing Address - Phone:979-779-2864
Mailing Address - Fax:979-779-8522
Practice Address - Street 1:702 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-3985
Practice Address - Country:US
Practice Address - Phone:979-779-2864
Practice Address - Fax:979-779-8522
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14921101YM0800X
TX12038104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator