Provider Demographics
NPI:1760718167
Name:CHILDERS, GINA ROSELETTE (BA)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:ROSELETTE
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N FAIRLAND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4225
Mailing Address - Country:US
Mailing Address - Phone:918-825-2884
Mailing Address - Fax:918-825-2234
Practice Address - Street 1:109 N FAIRLAND ST STE 101
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4225
Practice Address - Country:US
Practice Address - Phone:918-825-2884
Practice Address - Fax:918-825-2234
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor