MEDICARE: COMMUNITY COUNSELING CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	18834	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154323566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY COUNSELING CENTER

Provider Business Mailing Address
First Line	:	4757 MAIN AVE
Second Line	:
City	:	GROVES
State	:	TX
Zip	:	77619-4740
Country	:	US
Telephone Number	:	409-963-2331
Fax Number	:	409-963-2346

Provider Business Practice Location Address
First Line	:	4757 MAIN AVE
Second Line	:
City	:	GROVES
State	:	TX
Zip	:	77619-4740
Country	:	US
Telephone Number	:	409-963-2331
Fax Number	:	409-963-2346

Authorized Official
Title or Position	:	LICENSED PROF. COUNSELOR/THERAPIST
Name	:	MS. AMBER MALESCHA DEROUEN
Credential	:	MS, LPC
Telephone Number	:	409-963-2331

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	08/22/2008

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Directions to “COMMUNITY COUNSELING CENTER ” Practice Location

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