Provider Demographics
NPI:1124486519
Name:CHURCHILL, HEATHER (PSYD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 OAK ST
Mailing Address - Street 2:APT 4
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1882
Mailing Address - Country:US
Mailing Address - Phone:240-472-0153
Mailing Address - Fax:
Practice Address - Street 1:15 OAK ST
Practice Address - Street 2:APT 4
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1882
Practice Address - Country:US
Practice Address - Phone:413-931-5296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10297103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical