Provider Demographics
NPI:1417259995
Name:CHURCHILL, DAVID C (CPCI)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:CPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6171 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1126
Mailing Address - Country:US
Mailing Address - Phone:702-486-7596
Mailing Address - Fax:
Practice Address - Street 1:6171 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1126
Practice Address - Country:US
Practice Address - Phone:702-486-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-03
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5044101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1417259995Medicaid