Provider Demographics
NPI:1235720095
Name:CHURCH, VICTORIA (LAC)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3840
Mailing Address - Country:US
Mailing Address - Phone:701-222-0386
Mailing Address - Fax:
Practice Address - Street 1:7448 68TH AVE NE
Practice Address - Street 2:
Practice Address - City:CANDO
Practice Address - State:ND
Practice Address - Zip Code:58324-9485
Practice Address - Country:US
Practice Address - Phone:701-222-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2030101YA0400X
ND1440-5-15-25A101YP2500X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1481528Medicaid