Basic Information
| Provider Information | |||||||||
| NPI: | 1235244757 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY COUNSELING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5733345531 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5733345531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | TOLBERT | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5733341100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 290-7523 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 562624007 | 05 | MO | MEDICAID |