Provider Demographics
NPI:1164976940
Name:CHILDRESS, HUBERT JR (CI)
Entity Type:Individual
Prefix:
First Name:HUBERT
Middle Name:
Last Name:CHILDRESS
Suffix:JR
Gender:M
Credentials:CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W TWOHIG AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6321
Mailing Address - Country:US
Mailing Address - Phone:325-655-7777
Mailing Address - Fax:
Practice Address - Street 1:401 W TWOHIG AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6321
Practice Address - Country:US
Practice Address - Phone:325-655-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29802101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)