=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922534882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLABORATIVE COUNSELING ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 11/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1408 S SCHILLER ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72202-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-507-0675
-----------------------------------------------------
Fax | 501-421-0107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1408 S SCHILLER ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72202-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-507-0675
-----------------------------------------------------
Fax | 501-421-0107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INCORPORATOR/ MANAGING MEMBER
-----------------------------------------------------
Name | MRS. ANDREA M FRESH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 501-442-2293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------