Provider Demographics
NPI:1053312330
Name:CHURCH, MICHAEL ALLAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLAN
Last Name:CHURCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 WYOMING AVE
Mailing Address - Street 2:NESBITT HOSPITAL
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3721
Mailing Address - Country:US
Mailing Address - Phone:570-552-3891
Mailing Address - Fax:570-552-3891
Practice Address - Street 1:562 WYOMING AVE
Practice Address - Street 2:NESBITT HOSPITAL
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3721
Practice Address - Country:US
Practice Address - Phone:570-552-3891
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA003386103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
192492Medicare UPIN
R06596Medicare ID - Type Unspecified