Provider Demographics
NPI:1861507352
Name:CHURCHILL, JOHN EDWARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:EDWARD
Other - Last Name:CHURCHILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW BCD
Mailing Address - Street 1:5410 FREDERICKSBURG ROAD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3539
Mailing Address - Country:US
Mailing Address - Phone:210-524-9402
Mailing Address - Fax:210-524-9732
Practice Address - Street 1:5410 FREDERICKSBURG ROAD
Practice Address - Street 2:SUITE 111
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3539
Practice Address - Country:US
Practice Address - Phone:210-524-9402
Practice Address - Fax:210-524-9732
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS067471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA046170OtherVALUE OPTIONS
TXA046170OtherVALUE OPTIONS
S32811Medicare UPIN