Healthcare Provider Details

I. General information

NPI: 1467890293
Provider Name (Legal Business Name): WHITE COUNTY COMMUNITY COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S MAIN ST
MONTICELLO IN
47960
US

IV. Provider business mailing address

126 S MAIN ST
MONTICELLO IN
47960
US

V. Phone/Fax

Practice location:
  • Phone: 574-583-8055
  • Fax:
Mailing address:
  • Phone: 574-583-8055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002487A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number39002487A
License Number StateIN

VIII. Authorized Official

Name: MR. RICHARD CHARLES RUSSELL
Title or Position: DIRECTOR
Credential: LMHC
Phone: 574-583-8055