Provider Demographics
NPI:1023543790
Name:DOREEN CHURCH LCSW LLC
Entity Type:Organization
Organization Name:DOREEN CHURCH LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-662-0029
Mailing Address - Street 1:1663 EXECUTIVE PARK LN NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3130
Mailing Address - Country:US
Mailing Address - Phone:678-662-0029
Mailing Address - Fax:
Practice Address - Street 1:1663 EXECUTIVE PARK LN NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3130
Practice Address - Country:US
Practice Address - Phone:678-662-0029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0060261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty