MEDICARE: CLINICAL CONSULTATION & COUNSELING, P.A.

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)

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	:	1831416783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL CONSULTATION & COUNSELING, P.A.

Provider Business Mailing Address
First Line	:	PO BOX 370
Second Line	:
City	:	DOVER FOXCROFT
State	:	ME
Zip	:	04426-0370
Country	:	US
Telephone Number	:	207-564-0026
Fax Number	:	877-822-7919

Provider Business Practice Location Address
First Line	:	26 RIVER ST
Second Line	:	2ND FLOOR
City	:	DOVER FOXCROFT
State	:	ME
Zip	:	04426-1321
Country	:	US
Telephone Number	:	207-564-0026
Fax Number	:	877-822-7919

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID ARTHUR GOOLSBY
Credential	:	LCSW
Telephone Number	:	207-564-0026

Provider Enumeration Date	:	04/30/2010
Last Update Date	:	04/30/2010

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