Provider Demographics
NPI:1639235799
Name:CHILDS, GWENDOLYN J (MA, PSYD)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:J
Last Name:CHILDS
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 WATSON BAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6198
Mailing Address - Country:US
Mailing Address - Phone:770-413-1765
Mailing Address - Fax:770-498-8865
Practice Address - Street 1:1012 MAIN ST
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2944
Practice Address - Country:US
Practice Address - Phone:770-498-2865
Practice Address - Fax:770-498-8865
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001808103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000626381CMedicaid
GA10062758OtherPSYCHOLOGICAL SERVICE
GA280737000OtherPSYCHOLOGICAL SERVICE
GA582256356OtherPSYCHOLOGICAL
GA000626381CMedicaid