Provider Demographics
NPI:1265470744
Name:CHURCH, JOSEPH ALBERT III (OTR/L-CHT)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ALBERT
Last Name:CHURCH
Suffix:III
Gender:M
Credentials:OTR/L-CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2654
Mailing Address - Country:US
Mailing Address - Phone:228-575-4654
Mailing Address - Fax:228-575-4651
Practice Address - Street 1:1105 39TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2654
Practice Address - Country:US
Practice Address - Phone:228-575-4654
Practice Address - Fax:228-575-4651
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0116225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119593Medicaid
MS670000002Medicare PIN
MS00119593Medicaid