Provider Demographics
NPI:1699512640
Name:CHILDERS, LEONARD JAMES (LCSW, MSW)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:JAMES
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 E WASHINGTON ST STE 1D
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7309
Mailing Address - Country:US
Mailing Address - Phone:917-885-1344
Mailing Address - Fax:
Practice Address - Street 1:1211 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7309
Practice Address - Country:US
Practice Address - Phone:917-885-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0257291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical