MEDICARE: MR. JOHN EDWARD CHURCHILL LCSW

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	S06747	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A046170	OTHER	TX	VALUE OPTIONS

General Provider Information

NPI Number	:	1861507352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN EDWARD CHURCHILL LCSW

Provider Business Mailing Address
First Line	:	5410 FREDERICKSBURG ROAD
Second Line	:	SUITE 111
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3539
Country	:	US
Telephone Number	:	210-524-9402
Fax Number	:	210-524-9732

Provider Business Practice Location Address
First Line	:	5410 FREDERICKSBURG ROAD
Second Line	:	SUITE 111
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3539
Country	:	US
Telephone Number	:	210-524-9402
Fax Number	:	210-524-9732

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. JOHN EDWARD CHURCHILL LCSW” Practice Location

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