MEDICARE: MS. VIRGINIA A CHURCHILL

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1962458448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIRGINIA A CHURCHILL

Provider Business Mailing Address
First Line	:	2827 SE STEPHENS ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4969
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 SE 43RD AVE
Second Line	:	SUITE 100
City	:	PORTLAND
State	:	OR
Zip	:	97206-1600
Country	:	US
Telephone Number	:	503-797-6689
Fax Number	:

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	07/08/2007

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