Provider Demographics
NPI:1518105311
Name:NITA J CHILDERS
Entity Type:Organization
Organization Name:NITA J CHILDERS
Other - Org Name:NEW LIFE COUNSELING & ASSESSMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-984-7000
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75663-3428
Mailing Address - Country:US
Mailing Address - Phone:903-984-7000
Mailing Address - Fax:903-984-7001
Practice Address - Street 1:1100 STONE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5482
Practice Address - Country:US
Practice Address - Phone:903-984-7000
Practice Address - Fax:903-984-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1990301Medicaid
TX1990301Medicaid