Provider Demographics
NPI:1083989495
Name:CHURCH, ANGIE M (LCMHC)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:M
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-9034
Mailing Address - Fax:
Practice Address - Street 1:204 JEFFERSON ST STE 106
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3586
Practice Address - Country:US
Practice Address - Phone:336-838-1644
Practice Address - Fax:336-667-7720
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9140101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional