MEDICARE: COMMUNITY COUNSELING CENTERS INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	590142	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1487679973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY COUNSELING CENTERS INC

Provider Business Mailing Address
First Line	:	2550 SHOW LOW LAKE ROAD
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7929
Country	:	US
Telephone Number	:	928-537-1029
Fax Number	:	928-537-9049

Provider Business Practice Location Address
First Line	:	2550 SHOW LOW LAKE ROAD
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7929
Country	:	US
Telephone Number	:	928-537-1029
Fax Number	:	928-537-9049

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. IVAN ROBERT WILDERMAN
Credential	:	PHD
Telephone Number	:	928-524-6701

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	08/22/2020

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