Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 2-3301 | TX |
N | 103T00000X | Psychologist | 2-3301 | TX |
N | 103TS0200X | School Psychologist | 6637 | TX |
NPI | 1013064534 |
---|---|
Provider Name | Dr. Woody Cal Childress |
First Address | Fort Worth, TX 76116-1959 |
Second Address | Fort Worth, TX 76133-2254 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00D92R | (02) | TX |
P000D92R2 | (05) | TX |