Healthcare Provider Details

I. General information

NPI: 1063001378
Provider Name (Legal Business Name): TAMARA ELIZABETH CHURCH LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 PARK ST STE 101-1355
COLUMBIA SC
29201-2011
US

IV. Provider business mailing address

2000 PARK ST STE 101
COLUMBIA SC
29201-2011
US

V. Phone/Fax

Practice location:
  • Phone: 619-373-5121
  • Fax:
Mailing address:
  • Phone: 619-373-5121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09933413
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904017150
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34497
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16682
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18836
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5737C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: