Provider Demographics
NPI:1154465763
Name:COMMUNITY COUNSELING CENTER
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-1100
Mailing Address - Street 1:402 S SILVER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-7536
Mailing Address - Country:US
Mailing Address - Phone:573-334-1100
Mailing Address - Fax:
Practice Address - Street 1:402 S SILVER SPRINGS RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7536
Practice Address - Country:US
Practice Address - Phone:573-334-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2907523261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152624011Medicaid