Provider Demographics
NPI:1225581929
Name:CHURCH, DANIEL (LSW)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 IKE DR
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-9718
Mailing Address - Country:US
Mailing Address - Phone:808-579-8414
Mailing Address - Fax:
Practice Address - Street 1:200 IKE DR
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-9718
Practice Address - Country:US
Practice Address - Phone:808-579-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2272104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker