Provider Demographics
NPI:1184834277
Name:ROCKLIN COMMUNITY COUNSELING CENTER
Entity Type:Organization
Organization Name:ROCKLIN COMMUNITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:O'SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-315-0468
Mailing Address - Street 1:4240 ROCKLIN RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2862
Mailing Address - Country:US
Mailing Address - Phone:916-315-0468
Mailing Address - Fax:916-315-0462
Practice Address - Street 1:4240 ROCKLIN RD STE 5
Practice Address - Street 2:SUITE 5
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2862
Practice Address - Country:US
Practice Address - Phone:916-315-0468
Practice Address - Fax:916-315-0462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310009DN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3119Medicare ID - Type UnspecifiedPROVIDER NUMBER