Provider Demographics
NPI:1366742199
Name:CHURCH, NATHAN L (LCSW)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:L
Last Name:CHURCH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 JEMSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-6854
Mailing Address - Country:US
Mailing Address - Phone:406-694-5000
Mailing Address - Fax:406-245-1156
Practice Address - Street 1:527 LAKE ELMO DR
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-3051
Practice Address - Country:US
Practice Address - Phone:406-694-5000
Practice Address - Fax:406-245-1156
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1352101YA0400X
MT10431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1366742199Medicaid