Community Counseling Centers Inc
Organization Active NPI Mental Health Clinic/Center (Including Community Mental Health Center) · Winslow, AZ
NPI 1669413175 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1669413175
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
- License
- BH141 (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
- Organization subpart
- No
Authorized official
- Name
- Dr. Ivan Robert Wilderman, PH D
- Title
- Chief Executive Officer
- Phone
- (928) 624-6701
Other NPIs on the same Medicare enrollment 10
Practitioners 2
-
Karen M Blackwell, LMFT LISAC
-
Fred H Elsen, LMSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
Locations
211 E Third St
Winslow, AZ 86047
Phone (928) 289-4658
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Clinic/Center (Including Community Mental Health Center) | 261QM0801X | BH141 | AZ | Yes |
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
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 007452 | Other | AZ | AHCCCS |
Other providers in Winslow, AZ
- Community Bridges, Inc
- Community Bridges, Inc
- Community Bridges, Inc.
- Community Bridges, Inc.
- Community Bridges, Inc.
- Community Counseling Centers, Inc
- Kerry Lynn Cordier
- Stephanie M Crihfield
- Christina Curley
- Debra J Curley
All providers in Winslow, AZ · Mental Health Clinic/Center (Including Community Mental Health Center) in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.