NPIMap

Organization Active NPI

Community Counseling Centers Inc

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Winslow, AZ
National Provider Identifier
1669413175
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
License
BH141 Issued in AZ
Legal business name
COMMUNITY COUNSELING CENTERS INC
Practice address
211 East Third Street
Winslow, AZ 86047-3802
Phone
(928) 289-4658
Fax
(928) 289-3775
NPI assigned
Jun 8, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ivan Robert Wilderman, PH D
Title
Chief Executive Officer
Phone
(928) 624-6701

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X BH141 AZ Primary

Addresses

Primary practice location

211 East Third Street
Winslow, AZ 86047-3802

Mailing address

211 East Third Street
Winslow, AZ 86047-3802
Phone (928) 289-4658

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040625001074 AZ Part B Supplier - Clinic/Group Practice 8123004587 Receives reassigned benefits from 36 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Winslow, AZ; Snowflake, AZ; Pinetop, AZ; Show Low, AZ; Holbrook, AZ; Lakeside, AZ

Other NPIs on the same Medicare enrollment 10

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149724800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1669413175",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "211 EAST THIRD STREET",
            "city": "WINSLOW",
            "state": "AZ",
            "postal_code": "860473802",
            "telephone_number": "928-289-4658",
            "fax_number": "928-289-3775"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "211 EAST THIRD STREET",
            "city": "WINSLOW",
            "state": "AZ",
            "postal_code": "860473802",
            "telephone_number": "928-289-4658",
            "fax_number": "928-289-3775"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY COUNSELING CENTERS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-08",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WILDERMAN",
        "authorized_official_first_name": "IVAN",
        "authorized_official_middle_name": "ROBERT",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "928-624-6701",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PH D"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "AZ",
            "license": "BH141",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Winslow, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.