MEDICARE: COMMUNITY COUNSELING CENTERS INC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	BH141	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007452	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1669413175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY COUNSELING CENTERS INC

Provider Business Mailing Address
First Line	:	211 EAST THIRD STREET
Second Line	:
City	:	WINSLOW
State	:	AZ
Zip	:	86047-3802
Country	:	US
Telephone Number	:	928-289-4658
Fax Number	:	928-289-3775

Provider Business Practice Location Address
First Line	:	211 EAST THIRD STREET
Second Line	:
City	:	WINSLOW
State	:	AZ
Zip	:	86047-3802
Country	:	US
Telephone Number	:	928-289-4658
Fax Number	:	928-289-3775

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. IVAN ROBERT WILDERMAN
Credential	:	PH D
Telephone Number	:	928-624-6701

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	08/22/2020

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