Provider Demographics
NPI:1154323566
Name:COMMUNITY COUNSELING CENTER
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROF. COUNSELOR/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:MALESCHA
Authorized Official - Last Name:DEROUEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:409-963-2331
Mailing Address - Street 1:4757 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-4740
Mailing Address - Country:US
Mailing Address - Phone:409-963-2331
Mailing Address - Fax:409-963-2346
Practice Address - Street 1:4757 MAIN AVE
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-4740
Practice Address - Country:US
Practice Address - Phone:409-963-2331
Practice Address - Fax:409-963-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18834101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164006202Medicaid