Provider Demographics
NPI:1295825859
Name:CHURCH, JANICE (PHD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:CHURCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CHILDRENS WAY # 401
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-3810
Mailing Address - Fax:501-364-3416
Practice Address - Street 1:11 CHILDRENS WAY # 401
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-3810
Practice Address - Fax:501-364-3416
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR92-1P103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141633001Medicaid
AR141633001Medicaid