Healthcare Provider Details

I. General information

NPI: 1043304918
Provider Name (Legal Business Name): COMMUNITY CHRISTIAN COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9625 NORTH MILITARY TRAIL
PALM BEACH GARDENS FL
33410
US

IV. Provider business mailing address

9625 NORTH MILITARY TRAIL
PALM BEACH GARDENS FL
33410
US

V. Phone/Fax

Practice location:
  • Phone: 561-622-5423
  • Fax: 561-622-5467
Mailing address:
  • Phone: 561-622-5423
  • Fax: 561-622-5467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 7183
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT 0903
License Number StateFL

VIII. Authorized Official

Name: DR. WILLIAM G LARRISON
Title or Position: EXECUTIVE DIRECTOR
Credential: D. MIN.
Phone: 561-622-5423