Provider Demographics
NPI:1245677350
Name:CHILDRESS WILSON, CHRISTY DAWN (BSW)
Entity type:Individual
Prefix:MRS
First Name:CHRISTY
Middle Name:DAWN
Last Name:CHILDRESS WILSON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:OK
Mailing Address - Zip Code:74436-0485
Mailing Address - Country:US
Mailing Address - Phone:918-261-3554
Mailing Address - Fax:
Practice Address - Street 1:12270 N 345 RD
Practice Address - Street 2:
Practice Address - City:BOYNTON
Practice Address - State:OK
Practice Address - Zip Code:74422-4401
Practice Address - Country:US
Practice Address - Phone:918-261-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst