Basic Information
Provider Information | |||||||||
NPI: | 1124410808 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHILDRESS | ||||||||
FirstName: | KIM | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHILDRESS | ||||||||
OtherFirstName: | KIM | ||||||||
OtherMiddleName: | BROOME | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1939 S DIVISION AVE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 49507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6162473815 | ||||||||
FaxNumber: | 6162450450 | ||||||||
Practice Location | |||||||||
Address1: | 4565 WILSON AVE SW STE 3A | ||||||||
Address2: |   | ||||||||
City: | GRANDVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 49418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6164663107 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2015 | ||||||||
LastUpdateDate: | 10/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401015430 | MI | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.