MEDICARE: COLLABORATIVE COUNSELING ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	104100000X	Social Worker
2	1041S0200X	School Social Worker
3	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1326687070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLABORATIVE COUNSELING ASSOCIATES

Provider Business Mailing Address
First Line	:	1705 COPPERFIELD CIR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32312-3755
Country	:	US
Telephone Number	:	850-296-6811
Fax Number	:

Provider Business Practice Location Address
First Line	:	2834 REMINGTON GREEN CIR STE 104
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-3760
Country	:	US
Telephone Number	:	850-296-6811
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA JACKSON
Credential	:
Telephone Number	:	850-296-6811

Provider Enumeration Date	:	12/29/2019
Last Update Date	:	12/29/2019

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