Provider Demographics
NPI:1992403711
Name:CHURCH THERAPY ASSOCIATES, LLC
Entity type:Organization
Organization Name:CHURCH THERAPY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, LPC
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KANSIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:781-367-2383
Mailing Address - Street 1:4223 E STATE HIGHWAY AA
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-5772
Mailing Address - Country:US
Mailing Address - Phone:781-367-2383
Mailing Address - Fax:
Practice Address - Street 1:3112 W GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-5201
Practice Address - Country:US
Practice Address - Phone:781-367-2383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1053428722Medicaid