Basic Information
| Provider Information | |||||||||
| NPI: | 1336424233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILDRESS | ||||||||
| FirstName: | BRANDY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 24 MAIN ST N STE A | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587033104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015573782 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 MAIN ST N STE A | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587033104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015573782 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 09/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | PPC-941 | WY | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 986-1-1-19-A | ND | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 986-1-1-19 | ND | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 986-1-1-19-423 | ND | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 986-1-1-19-423 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.