Provider Demographics
NPI:1528711330
Name:CHILDRESS, ANTOINETTE
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:CHILDRESS
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 1:1205 E INTERNATIONAL AIRPORT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-1409
Mailing Address - Country:US
Mailing Address - Phone:907-575-1585
Mailing Address - Fax:
Practice Address - Street 1:6225 E TUDOR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1250
Practice Address - Country:US
Practice Address - Phone:907-575-1585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
AK179636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional