Provider Demographics
NPI:1467985093
Name:CHURCH, DOREEN R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DOREEN
Middle Name:R
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DOREEN
Other - Middle Name:R
Other - Last Name:MCCANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4530 S BERKELEY LAKE RD
Mailing Address - Street 2:STE B
Mailing Address - City:BERKELEY LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1657
Mailing Address - Country:US
Mailing Address - Phone:678-662-0029
Mailing Address - Fax:770-446-5643
Practice Address - Street 1:4530 S BERKELEY LAKE RD
Practice Address - Street 2:STE B
Practice Address - City:BERKELEY LAKE
Practice Address - State:GA
Practice Address - Zip Code:30071-1657
Practice Address - Country:US
Practice Address - Phone:678-662-0029
Practice Address - Fax:770-446-5643
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0060261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical