Provider Demographics
NPI:1801959432
Name:CHILDRESS, DEMETRA (MS)
Entity type:Individual
Prefix:MS
First Name:DEMETRA
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 JUAN TABO BLVD NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2681
Mailing Address - Country:US
Mailing Address - Phone:505-292-8908
Mailing Address - Fax:505-292-3109
Practice Address - Street 1:4425 JUAN TABO BLVD NE
Practice Address - Street 2:SUITE 103
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2681
Practice Address - Country:US
Practice Address - Phone:505-292-8908
Practice Address - Fax:505-292-3109
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0975101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01357573Medicaid
NM201012073OtherPRESBYTERIAN HEALTH PLAN
NMNM101536OtherVALUE OPTIONS SALVD