Provider Demographics
NPI:1558018168
Name:CHURCH, TARYN LEIGH (MA LMHC)
Entity Type:Individual
Prefix:
First Name:TARYN
Middle Name:LEIGH
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 ROAD 3900
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3203
Mailing Address - Country:US
Mailing Address - Phone:719-200-2905
Mailing Address - Fax:
Practice Address - Street 1:475 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2151
Practice Address - Country:US
Practice Address - Phone:505-327-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0222211101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health