Healthcare Provider Details

I. General information

NPI: 1154465763
Provider Name (Legal Business Name): COMMUNITY COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S SILVER SPRINGS RD
CAPE GIRARDEAU MO
63703-7536
US

IV. Provider business mailing address

402 S SILVER SPRINGS RD
CAPE GIRARDEAU MO
63703-7536
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-1100
  • Fax:
Mailing address:
  • Phone: 573-334-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2907523
License Number StateMO

VIII. Authorized Official

Name: LISA TOLBERT
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 573-334-1100