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General NPI Number Information
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NPI Number | 1962915579
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Entity Type | Organization
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Legal Business Name | COLLABORATIVE COUNSELING GROUP
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Dates
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Enumeration Date | 11/06/2017
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Last Update Date | 01/24/2018
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Provider Practice Location Address
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Address Line | 208 N MULBERRY ST
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-1464
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Country | US
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Telephone | 270-312-2860
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Fax | 270-312-2860
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Provider Business Mailing Address
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Address Line | 202 N MULBERRY ST
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-1441
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Country | US
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Telephone | 270-312-2860
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | PHYLLIS K LONNEMAN
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Credential | LPCC
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Telephone | 270-234-0267
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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 |
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License Number State |
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