Provider Demographics
NPI:1013064534
Name:CHILDRESS, WOODY CAL (PHD)
Entity Type:Individual
Prefix:DR
First Name:WOODY
Middle Name:CAL
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 ADEN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-1959
Mailing Address - Country:US
Mailing Address - Phone:817-731-2468
Mailing Address - Fax:
Practice Address - Street 1:5658 WESTCREEK DR STE 400
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-2254
Practice Address - Country:US
Practice Address - Phone:817-731-2468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3301103T00000X
TX6637103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000D92R2Medicaid
TX00D92RMedicare UPIN
TX00D92RMedicare ID - Type Unspecified