Basic Information
| Provider Information | |||||||||
| NPI: | 1063894376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILDRESS | ||||||||
| FirstName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12978 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731572978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058582700 | ||||||||
| FaxNumber: | 4058582810 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 S DIVISION ST | ||||||||
| Address2: | SUITE C & D | ||||||||
| City: | GUTHRIE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730446027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052603441 | ||||||||
| FaxNumber: | 4052603442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 1240 | OK | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.