Provider Demographics
NPI:1275836108
Name:CHILDERS, KIMBERLY (LPC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21741 RAUSCH AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2537
Mailing Address - Country:US
Mailing Address - Phone:313-689-5813
Mailing Address - Fax:586-443-4498
Practice Address - Street 1:21741 RAUSCH AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2537
Practice Address - Country:US
Practice Address - Phone:313-689-5813
Practice Address - Fax:586-443-4498
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009988101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional