Provider Demographics
NPI:1760160311
Name:CHILDERS, BREANNA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 PIKE ALY APT 2
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42629-2225
Mailing Address - Country:US
Mailing Address - Phone:916-293-6887
Mailing Address - Fax:270-380-1711
Practice Address - Street 1:203 BURKESVILLE ST STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-1900
Practice Address - Country:US
Practice Address - Phone:270-250-5070
Practice Address - Fax:270-380-1711
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician