Basic Information
| Provider Information | |||||||||
| NPI: | 1437596426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARSON CITY COMMUNITY COUNSELING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 S PRATT AVE | ||||||||
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| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897014730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758823945 | ||||||||
| FaxNumber: | 7758826126 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 E LONG ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897063129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758413223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 05/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRYAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7758823945 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | CC-02 10115 | NV | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.