Healthcare Provider Details

I. General information

NPI: 1215436803
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: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4546 ASHLAND AVE
SAINT LOUIS MO
63115-2330
US

IV. Provider business mailing address

4546 ASHLAND AVE
SAINT LOUIS MO
63115-2330
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 Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 6
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