Provider Demographics
NPI:1972664548
Name:CHILDERS, BETH M (PT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:M
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 DEVON RD
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-5205
Mailing Address - Country:US
Mailing Address - Phone:985-212-1660
Mailing Address - Fax:
Practice Address - Street 1:231 DEVON RD
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-5205
Practice Address - Country:US
Practice Address - Phone:985-212-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00336225100000X
TX1027837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1503436Medicaid