Provider Demographics
NPI:1093048282
Name:CHURCH, JOHN R (LMHC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:CHURCH
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3563
Mailing Address - Country:US
Mailing Address - Phone:319-215-8197
Mailing Address - Fax:
Practice Address - Street 1:847 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-2141
Practice Address - Country:US
Practice Address - Phone:319-215-8197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-07
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001065101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health