Provider Demographics
NPI:1720588783
Name:CHURCH, ANN CLAY (MA)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:CLAY
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7804 FAIRVIEW RD STE C288
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-4998
Mailing Address - Country:US
Mailing Address - Phone:980-295-3952
Mailing Address - Fax:
Practice Address - Street 1:7804 FAIRVIEW RD STE C288
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-4998
Practice Address - Country:US
Practice Address - Phone:980-285-3952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional