Provider Demographics
NPI:1912349457
Name:CHILDRESS, AMY LAUREN (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LAUREN
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 HIGHWAY 190
Mailing Address - Street 2:APT 614
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3470
Mailing Address - Country:US
Mailing Address - Phone:504-575-4947
Mailing Address - Fax:
Practice Address - Street 1:1901 HIGHWAY 190
Practice Address - Street 2:APT 614
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3470
Practice Address - Country:US
Practice Address - Phone:504-575-4947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1213103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool