Provider Demographics
NPI:1972846814
Name:CHURCH, NOVEMBER THEA
Entity type:Individual
Prefix:
First Name:NOVEMBER
Middle Name:THEA
Last Name:CHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 VONDERBURG DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5954
Mailing Address - Country:US
Mailing Address - Phone:813-881-1000
Mailing Address - Fax:813-689-2684
Practice Address - Street 1:510 VONDERBURG DR
Practice Address - Street 2:SUITE 301
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5954
Practice Address - Country:US
Practice Address - Phone:813-881-1000
Practice Address - Fax:813-689-2684
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11735101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health