Provider Demographics
NPI:1518650019
Name:CHURCH, SHANDIIN A
Entity Type:Individual
Prefix:MS
First Name:SHANDIIN
Middle Name:A
Last Name:CHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12724 SAN JUAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1638
Mailing Address - Country:US
Mailing Address - Phone:505-917-1101
Mailing Address - Fax:
Practice Address - Street 1:5201 VENICE AVE NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2337
Practice Address - Country:US
Practice Address - Phone:505-916-2007
Practice Address - Fax:505-433-4490
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical