Provider Demographics
NPI:1871235655
Name:CHURCH, CLARENCE AUSTIN III (LMHC)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:AUSTIN
Last Name:CHURCH
Suffix:III
Gender:M
Credentials: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:719-502-1366
Mailing Address - Fax:
Practice Address - Street 1:2901 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4411
Practice Address - Country:US
Practice Address - Phone:505-326-0241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTL0222201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty