Healthcare Provider Details

I. General information

NPI: 1467985093
Provider Name (Legal Business Name): DOREEN R CHURCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DOREEN R MCCANN

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 06/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 S BERKELEY LAKE RD STE B
BERKELEY LAKE GA
30071-1657
US

IV. Provider business mailing address

4530 S BERKELEY LAKE RD STE B
BERKELEY LAKE GA
30071-1657
US

V. Phone/Fax

Practice location:
  • Phone: 678-662-0029
  • Fax: 770-446-5643
Mailing address:
  • Phone: 678-662-0029
  • Fax: 770-446-5643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006026
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: