Provider Demographics
NPI:1093390825
Name:CHILDERS, ALYSSA NICOLE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 DOVER ST APT 11
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1962
Mailing Address - Country:US
Mailing Address - Phone:971-266-7806
Mailing Address - Fax:
Practice Address - Street 1:3125 DOVER ST APT 11
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1962
Practice Address - Country:US
Practice Address - Phone:971-266-7806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA101366194OtherUNITED HEALTHCARE