Provider Demographics
NPI:1043704331
Name:CENTRAL COUNSELING SERVICES LICENSED CLINICAL SOCIAL WORKER INC
Entity Type:Organization
Organization Name:CENTRAL COUNSELING SERVICES LICENSED CLINICAL SOCIAL WORKER INC
Other - Org Name:CENTRAL COUNSELING SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OPERATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHERALYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHOCKEY-POPE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-778-0230
Mailing Address - Street 1:6840 INDIANA AVE STE 275
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4279
Mailing Address - Country:US
Mailing Address - Phone:951-778-0230
Mailing Address - Fax:
Practice Address - Street 1:6840 INDIANA AVE STE 275
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4279
Practice Address - Country:US
Practice Address - Phone:951-778-0230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL COUNSELING SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-19
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268721041C0700X
CA37209106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty