Healthcare Provider Details

I. General information

NPI: 1932664190
Provider Name (Legal Business Name): DCCCA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S NINNESCAH ST
PRATT KS
67124-2838
US

IV. Provider business mailing address

3312 CLINTON PKWY
LAWRENCE KS
66047-3624
US

V. Phone/Fax

Practice location:
  • Phone: 620-672-7546
  • Fax: 620-672-7148
Mailing address:
  • Phone: 785-841-4138
  • Fax: 785-841-5777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KERYE J JACKSON
Title or Position: CFO
Credential:
Phone: 785-841-4138