MEDICARE: CCCC COUNSELING 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1942435219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCCC COUNSELING LLC

Provider Business Mailing Address
First Line	:	3262 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2883
Country	:	US
Telephone Number	:	260-438-8907
Fax Number	:

Provider Business Practice Location Address
First Line	:	3262 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2883
Country	:	US
Telephone Number	:	260-438-8907
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. STACIE ANN KREIGER
Credential	:
Telephone Number	:	260-438-8907

Provider Enumeration Date	:	05/15/2009
Last Update Date	:	05/15/2009

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