Provider Demographics
NPI:1205833449
Name:CHILDERSTON, JAMES K (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:K
Last Name:CHILDERSTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 OPAL CT
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5940
Mailing Address - Country:US
Mailing Address - Phone:301-797-2110
Mailing Address - Fax:301-797-2379
Practice Address - Street 1:1146 OPAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5940
Practice Address - Country:US
Practice Address - Phone:301-797-2110
Practice Address - Fax:301-797-2379
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2307103TC0700X
MD02307103TC1900X, 103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG017JKMedicare ID - Type Unspecified