Provider Demographics
NPI:1649499203
Name:CHILDRESS, CRAIG ALAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALAN
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 BOGIE DR.
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5144
Mailing Address - Country:US
Mailing Address - Phone:909-821-5398
Mailing Address - Fax:
Practice Address - Street 1:2124 BOGIE DR
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-1303
Practice Address - Country:US
Practice Address - Phone:909-821-5398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18857103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical