Provider Demographics
NPI:1659774180
Name:CHILDRESS, PATRICK LAWRENCE (DPT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:LAWRENCE
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:DESTREHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70047-2117
Mailing Address - Country:US
Mailing Address - Phone:504-289-0136
Mailing Address - Fax:
Practice Address - Street 1:1972 ORMOND BLVD
Practice Address - Street 2:
Practice Address - City:DESTREHAN
Practice Address - State:LA
Practice Address - Zip Code:70047-3818
Practice Address - Country:US
Practice Address - Phone:985-307-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist