Provider Demographics
NPI:1770288730
Name:CHURCH, DANIEL W
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:CHURCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 SEA ISLE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-6635
Mailing Address - Country:US
Mailing Address - Phone:678-643-3550
Mailing Address - Fax:
Practice Address - Street 1:4801 SEA ISLE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-6635
Practice Address - Country:US
Practice Address - Phone:678-643-3550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor