Provider Demographics
NPI:1215967161
Name:CHILDRESS, AMY (MED, CCC/SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:MED, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 KNIGHTON LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2683
Mailing Address - Country:US
Mailing Address - Phone:609-304-0244
Mailing Address - Fax:856-234-7475
Practice Address - Street 1:19 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2172
Practice Address - Country:US
Practice Address - Phone:609-304-0244
Practice Address - Fax:856-234-7475
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00409200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist