Provider Demographics
NPI:1174095020
Name:CHURCHWARD, JOHN LAWRENCE SR (CDP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LAWRENCE
Last Name:CHURCHWARD
Suffix:SR
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 S D ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-6813
Mailing Address - Country:US
Mailing Address - Phone:253-798-3545
Mailing Address - Fax:
Practice Address - Street 1:3629 S D ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-6813
Practice Address - Country:US
Practice Address - Phone:253-798-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CP60437986101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)