Provider Demographics
NPI:1114466497
Name:CHURCH, BILLIE
Entity Type:Individual
Prefix:
First Name:BILLIE
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BILLIE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:22444 W MADRE DEL ORO DR
Mailing Address - Street 2:
Mailing Address - City:WITTMANN
Mailing Address - State:AZ
Mailing Address - Zip Code:85361-8656
Mailing Address - Country:US
Mailing Address - Phone:602-326-4801
Mailing Address - Fax:
Practice Address - Street 1:22444 W MADRE DEL ORO DR
Practice Address - Street 2:
Practice Address - City:WITTMANN
Practice Address - State:AZ
Practice Address - Zip Code:85361-8656
Practice Address - Country:US
Practice Address - Phone:602-326-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-19
Last Update Date:2017-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health