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General NPI Number Information
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NPI Number | 1245673482
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Entity Type | Organization
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Legal Business Name | COMMUNITY OUTREACH COUNSELING PC
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Dates
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Enumeration Date | 04/08/2013
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Last Update Date | 09/03/2013
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Provider Practice Location Address
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Address Line | 1617 HIGHWAY 12 E SUITE 230
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City | WILLMAR
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State | MN
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Zip | 56201-5814
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Country | US
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Telephone | 320-905-0795
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Fax | 320-205-0030
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Provider Business Mailing Address
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Address Line | 1617 HIGHWAY 12 E SUITE 230
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City | WILLMAR
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State | MN
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Zip | 56201-5814
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Country | US
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Telephone | 320-905-0795
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Fax | 320-205-0030
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Authorized Official
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Title or Position | OWNER
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Name | MR. TIMOTHY R JOHNSON
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Credential | MA LMFT
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Telephone | 320-905-0795
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1071
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License Number State | MN
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