Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 2834-057 | WI |
Y | 103G00000X | Clinical Psychologist | 2834-057 | WI |
Y | 103TC0700X | Clinical Psychologist | 2834-057 | WI |
N | 103TC1900X | Counseling Psychologist | 2834-057 | WI |
N | 103TF0200X | Forensic Psychologist | 2834-057 | WI |
N | 103TH0004X | Health Psychologist | 2834-057 | WI |
NPI | 1285960518 |
---|---|
Provider Name | Dr. Craig D. Childs |
First Address | Delafield, WI 53018-2322 |
Second Address | Delafield, WI 53018-2322 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2009 |
Last Update Date | 20/06/2013 |