Healthcare Provider Details

I. General information

NPI: 1992823249
Provider Name (Legal Business Name): COMMUNITY COUNSELING CENTER OF SOUTHERN UTAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 N 100 E STE 204
ST GEORGE UT
84770-2893
US

IV. Provider business mailing address

PO BOX 3001
CEDAR CITY UT
84721-3001
US

V. Phone/Fax

Practice location:
  • Phone: 435-674-9449
  • Fax:
Mailing address:
  • Phone: 435-652-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: CHRIS DOSS
Title or Position: REGISTERED AGENT
Credential: LCSW
Phone: 435-669-8970