Provider Demographics
NPI:1740662881
Name:CHILDRESS, BRYONY S (MSW, LISW-CP)
Entity type:Individual
Prefix:MS
First Name:BRYONY
Middle Name:S
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:MSW, LISW-CP
Other - Prefix:MS
Other - First Name:BRIE
Other - Middle Name:
Other - Last Name:CHILDRESS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LISW-CP
Mailing Address - Street 1:2400 LANE AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3204
Mailing Address - Country:US
Mailing Address - Phone:864-359-8888
Mailing Address - Fax:864-722-0261
Practice Address - Street 1:2400 LANE AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3204
Practice Address - Country:US
Practice Address - Phone:864-878-6830
Practice Address - Fax:864-878-5396
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8873104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLW1044Medicaid