Provider Demographics
NPI:1801397997
Name:CHILDS, ANNA JO (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:JO
Last Name:CHILDS
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 S AVON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILLIPS
Mailing Address - State:WI
Mailing Address - Zip Code:54555-1308
Mailing Address - Country:US
Mailing Address - Phone:715-663-0717
Mailing Address - Fax:
Practice Address - Street 1:148 S AVON AVE
Practice Address - Street 2:
Practice Address - City:PHILLIPS
Practice Address - State:WI
Practice Address - Zip Code:54555-1308
Practice Address - Country:US
Practice Address - Phone:715-663-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9380-1231041C0700X
WI132-16012101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801397997Medicaid