Provider Demographics
NPI:1083988208
Name:CHILDS, CEPHUS JR
Entity Type:Individual
Prefix:
First Name:CEPHUS
Middle Name:
Last Name:CHILDS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-3335
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:409 CUSTER WAY SE
Practice Address - Street 2:STE D
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-3350
Practice Address - Country:US
Practice Address - Phone:360-570-8258
Practice Address - Fax:360-570-1171
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60196684106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist