Provider Demographics
NPI:1891862462
Name:CHURCH, EDWARD THOMAS III (LPCC)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:THOMAS
Last Name:CHURCH
Suffix:III
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 BLUE RIDGE PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4168
Mailing Address - Country:US
Mailing Address - Phone:505-299-1634
Mailing Address - Fax:
Practice Address - Street 1:1330 SAN PEDRO DR NE
Practice Address - Street 2:SUITE 201B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6744
Practice Address - Country:US
Practice Address - Phone:505-260-9912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0085761101YM0800X, 101YP2500X
101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional