Healthcare Provider Details

I. General information

NPI: 1699064188
Provider Name (Legal Business Name): COMMUNITY COUNSELING CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 E FIRST ST
WINSLOW AZ
86047-4104
US

IV. Provider business mailing address

1008 E FIRST ST
WINSLOW AZ
86047-4104
US

V. Phone/Fax

Practice location:
  • Phone: 928-289-3383
  • Fax: 928-289-3385
Mailing address:
  • Phone: 928-289-3383
  • Fax: 928-289-3385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: BETH CARLSON
Title or Position: PROGRAM MANAGER
Credential:
Phone: 928-289-3383