Healthcare Provider Details

I. General information

NPI: 1477052058
Provider Name (Legal Business Name): THE COMMUNITY COUNSELING & HOUSING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2407 PETROVA AVE
JENNINGS MO
63136-3903
US

IV. Provider business mailing address

4166 LINDELL BLVD APT 1B
SAINT LOUIS MO
63108-2923
US

V. Phone/Fax

Practice location:
  • Phone: 314-580-3029
  • Fax:
Mailing address:
  • Phone: 314-580-3029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: DR. MARVIN SHELTON
Title or Position: CEO
Credential: ED.S, ED.D, RADC-P
Phone: 314-580-3029