Provider Demographics
NPI:1457409575
Name:CHURCH, RICHARD LYLE (MA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LYLE
Last Name:CHURCH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PLC
Mailing Address - Street 1:4300 LONDONDERRY AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2758
Mailing Address - Country:US
Mailing Address - Phone:269-760-6265
Mailing Address - Fax:
Practice Address - Street 1:4031 W MAIN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-3730
Practice Address - Country:US
Practice Address - Phone:269-760-6265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000376101YP2500X
MI68010581331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical