Provider Demographics
NPI:1235195629
Name:CHURCHILL, STEPHANIE L (LMFT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-1513
Mailing Address - Country:US
Mailing Address - Phone:802-748-5364
Mailing Address - Fax:
Practice Address - Street 1:231 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-1513
Practice Address - Country:US
Practice Address - Phone:802-748-5364
Practice Address - Fax:802-748-7289
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1000000044106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012018Medicaid