Healthcare Provider Details

I. General information

NPI: 1255005575
Provider Name (Legal Business Name): CONSULTING & COMMUNITY RESOURCES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 09/06/2023
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 MT VERNON AVE
PORTSMOUTH VA
23707-3511
US

IV. Provider business mailing address

1535 MT VERNON AVE
PORTSMOUTH VA
23707-3511
US

V. Phone/Fax

Practice location:
  • Phone: 757-409-2851
  • Fax:
Mailing address:
  • Phone: 757-409-2851
  • 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 Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: KATHY L JOHNSON
Title or Position: QDIP/ OWNER
Credential:
Phone: 757-409-2851