Provider Demographics
NPI:1801908561
Name:CHILDERS, VERL O JR (PH D)
Entity type:Individual
Prefix:DR
First Name:VERL
Middle Name:O
Last Name:CHILDERS
Suffix:JR
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2994 FM 66
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:TX
Mailing Address - Zip Code:76055-5110
Mailing Address - Country:US
Mailing Address - Phone:254-687-2494
Mailing Address - Fax:
Practice Address - Street 1:2994 FM 66
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:TX
Practice Address - Zip Code:76055-5110
Practice Address - Country:US
Practice Address - Phone:254-687-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22103103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00SD07OtherBLUE CROSS BLUE SHIELD