MEDICARE: WESLEY T CHURCH JR. PHD. LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2025028062	MO

General Provider Information

NPI Number	:	1811786718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WESLEY T CHURCH JR. PHD. LMSW

Provider Business Mailing Address
First Line	:	PO BOX 844715
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64184-4715
Country	:	US
Telephone Number	:	417-761-5214
Fax Number	:	417-761-5065

Provider Business Practice Location Address
First Line	:	1736 N PLANTATION DR
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-6300
Country	:	US
Telephone Number	:	417-761-5495
Fax Number	:	417-761-5496

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2025
Last Update Date	:	07/09/2025

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