Provider Demographics
NPI:1568662781
Name:CHILDRESS, JOHN MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:LCSW
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Other - First Name:
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Mailing Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:650 JOLE DRIVE
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5349
Mailing Address - Country:US
Mailing Address - Phone:270-798-8727
Mailing Address - Fax:270-956-0180
Practice Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:650 JOLE DRIVE
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5349
Practice Address - Country:US
Practice Address - Phone:270-798-8727
Practice Address - Fax:270-956-0180
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PACW0150171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYVAD001OtherUPIN