Provider Demographics
NPI:1588113849
Name:CHURCHILL, DAVID DIEDERICH (LMFT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:DIEDERICH
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 S TOWER RD
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-5505
Mailing Address - Country:US
Mailing Address - Phone:218-736-6987
Mailing Address - Fax:182-736-6980
Practice Address - Street 1:980 S TOWER RD
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-5505
Practice Address - Country:US
Practice Address - Phone:218-736-6987
Practice Address - Fax:218-736-6980
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3351106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist