Basic Information
| Provider Information | |||||||||
| NPI: | 1770969933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILDERS | ||||||||
| FirstName: | KEELY | ||||||||
| MiddleName: | STRAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 CLANTON RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048651558 | ||||||||
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| Practice Location | |||||||||
| Address1: | 549 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280540628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048651558 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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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 | 101YA0400X | LCAS-22047 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | A11707 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.