MEDICARE: CORE CONNECT COUNSELING & CONSULTING LLC

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	101YP2500X	Professional Counselor	16744	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1326444324	OTHER	AZ	PROVIDER NPI

General Provider Information

NPI Number	:	1205321460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORE CONNECT COUNSELING & CONSULTING LLC

Provider Business Mailing Address
First Line	:	152 N POWER RD STE 2
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-8436
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	152 N POWER RD STE 2
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-8436
Country	:	US
Telephone Number	:	480-428-8998
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR
Name	:	KATHERINE G PEREZ
Credential	:	LPC
Telephone Number	:	480-428-8998

Provider Enumeration Date	:	06/28/2018
Last Update Date	:	06/28/2018

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