Provider Demographics
NPI:1497808562
Name:CHILDERS, PAULA MARGARET (LICSW)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:MARGARET
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10540 XERXES AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3336
Mailing Address - Country:US
Mailing Address - Phone:952-886-9158
Mailing Address - Fax:
Practice Address - Street 1:2419 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3450
Practice Address - Country:US
Practice Address - Phone:612-871-3320
Practice Address - Fax:612-871-0432
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5734OtherLICSW