=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952880973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR CLINICAL COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2018
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 ELLIS ST STE 3A
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30901-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-526-7717
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 ELLIS ST STE 3A
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30901-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-526-7717
-----------------------------------------------------
Fax | 706-755-2860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CASSANDRA L JOHNSON
-----------------------------------------------------
Credential | PHD LPC
-----------------------------------------------------
Telephone | 706-526-7717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------