Provider Demographics
NPI:1790496297
Name:CHILDERS, ATHENIA (BS, MSCJO, QMPH - R)
Entity Type:Individual
Prefix:
First Name:ATHENIA
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:BS, MSCJO, QMPH - R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3256
Mailing Address - Country:US
Mailing Address - Phone:360-414-2236
Mailing Address - Fax:
Practice Address - Street 1:600 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3256
Practice Address - Country:US
Practice Address - Phone:360-414-2236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health