Provider Demographics
NPI:1538759444
Name:CHURCH, HERBERT S (LPC)
Entity type:Individual
Prefix:MR
First Name:HERBERT
Middle Name:S
Last Name:CHURCH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 MEDLEY CT NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-6971
Mailing Address - Country:US
Mailing Address - Phone:770-617-7421
Mailing Address - Fax:
Practice Address - Street 1:209B SWANTON WAY STE 204
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3271
Practice Address - Country:US
Practice Address - Phone:404-354-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010749101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty