Provider Demographics
NPI:1063728772
Name:CHILDERS, MARY ALICE
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ALICE
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 LOUDENS CHAPEL RD NW
Mailing Address - Street 2:
Mailing Address - City:DEPAUW
Mailing Address - State:IN
Mailing Address - Zip Code:47115-8745
Mailing Address - Country:US
Mailing Address - Phone:812-972-0009
Mailing Address - Fax:
Practice Address - Street 1:4040 LOUDENS CHAPEL RD NW
Practice Address - Street 2:
Practice Address - City:DEPAUW
Practice Address - State:IN
Practice Address - Zip Code:47115-8745
Practice Address - Country:US
Practice Address - Phone:812-972-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist