Basic Information
| Provider Information | |||||||||
| NPI: | 1942433636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 DOMINGO RD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052685295 | ||||||||
| FaxNumber: | 5052689967 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 DOMINGO RD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052685295 | ||||||||
| FaxNumber: | 5052689967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2009 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0096261 | NM | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | CCMH0096261 | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | B9311 | 05 | NM | MEDICAID |