=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619163516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSE LINDA CHURCHILL MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 03/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1230 N ANDERSON RD
-----------------------------------------------------
City | EXETER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93221-9674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-799-8531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6682
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93290-6682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-799-8530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC36092
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------