Healthcare Provider Details

I. General information

NPI: 1518225473
Provider Name (Legal Business Name): COMMUNITY COUNSELING CENTER OF ASHTABULA COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 C CT
ASHTABULA OH
44004-4577
US

IV. Provider business mailing address

2801 C CT
ASHTABULA OH
44004-4577
US

V. Phone/Fax

Practice location:
  • Phone: 440-998-4210
  • Fax: 440-998-6489
Mailing address:
  • Phone: 440-998-4210
  • Fax: 440-998-6489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATHY REGAL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MBA
Phone: 440-998-4210