Healthcare Provider Details

I. General information

NPI: 1124276563
Provider Name (Legal Business Name): TINA MARIE CHURCHILL MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 N. HIGHWAY 47 SUITE A
WARRENTON MO
63383-1375
US

IV. Provider business mailing address

1428 N STATE HIGHWAY 47 STE C
WARRENTON MO
63383-1375
US

V. Phone/Fax

Practice location:
  • Phone: 636-359-6445
  • Fax: 636-456-6216
Mailing address:
  • Phone: 636-359-6445
  • Fax: 636-377-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2005010044
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: