Basic Information
| Provider Information | |||||||||
| NPI: | 1992176036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILDRES | ||||||||
| FirstName: | STACEY | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1210 ALDERSGATE RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015743053 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1210 ALDERSGATE RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015743053 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2015 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-15-19879 | AR | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.