Healthcare Provider Details

I. General information

NPI: 1891862462
Provider Name (Legal Business Name): EDWARD THOMAS CHURCH III LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SAN PEDRO DR NE SUITE 201B
ALBUQUERQUE NM
87110-6744
US

IV. Provider business mailing address

4001 BLUE RIDGE PL NE
ALBUQUERQUE NM
87111-4168
US

V. Phone/Fax

Practice location:
  • Phone: 505-260-9912
  • Fax:
Mailing address:
  • Phone: 505-299-1634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0085761
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0085761
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: