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General NPI Number Information
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NPI Number | 1700390374
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Entity Type | Organization
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Legal Business Name | COMMUNITY COUNSELING & EVALUATION SERVICES, LLC
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Dates
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Enumeration Date | 11/18/2017
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Last Update Date | 11/18/2017
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Provider Practice Location Address
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Address Line | 115 S MAIN ST
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City | JEFFERSON
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State | WI
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Zip | 53549-1631
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Country | US
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Telephone | 920-728-1125
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Fax |
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Provider Business Mailing Address
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Address Line | 125 E WOOLCOCK ST
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City | JEFFERSON
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State | WI
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Zip | 53549-1234
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Country | US
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Telephone | 920-728-1125
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MS. TAMMY JANE KING
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Credential | LCSW
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Telephone | 920-728-1125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 6752-123
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License Number State | WI
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