Basic Information
| Provider Information | |||||||||
| NPI: | 1821360926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHILDRESS | ||||||||
| FirstName: | TYRONE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS/MHC, LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4173 11TH ST | ||||||||
| Address2: | |||||||||
| City: | ECORSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482291220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132547034 | ||||||||
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| Practice Location | |||||||||
| Address1: | 114 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488587766 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401012248 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.