Provider Demographics
NPI:1720098981
Name:CHILDERS, DANIEL JOSEPH
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 738
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-0738
Mailing Address - Country:US
Mailing Address - Phone:315-383-7531
Mailing Address - Fax:315-221-4382
Practice Address - Street 1:210 COURT ST
Practice Address - Street 2:SUITE 4
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4546
Practice Address - Country:US
Practice Address - Phone:315-383-7531
Practice Address - Fax:315-221-4382
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO0574061104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02426997Medicaid
NY02426997Medicaid
NYCC2950Medicare UPIN