Provider Demographics
NPI:1518083039
Name:CHURCH, CHARY ROBERTA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:CHARY
Middle Name:ROBERTA
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 MEDLEY CT NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-6971
Mailing Address - Country:US
Mailing Address - Phone:770-218-3719
Mailing Address - Fax:
Practice Address - Street 1:110 EVANS MILL DR STE 305
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-1623
Practice Address - Country:US
Practice Address - Phone:770-445-6358
Practice Address - Fax:770-445-7262
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004233101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional