Provider Demographics
NPI:1710567714
Name:CHURCH, MYSTI JO (LMSW)
Entity Type:Individual
Prefix:
First Name:MYSTI
Middle Name:JO
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5110
Mailing Address - Country:US
Mailing Address - Phone:575-885-4836
Mailing Address - Fax:505-443-8319
Practice Address - Street 1:914 N CANAL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5110
Practice Address - Country:US
Practice Address - Phone:575-885-4836
Practice Address - Fax:505-443-8319
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM172V00000X
NMSWB-2023-0090104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02486417000Medicaid