Provider Demographics
NPI:1346457157
Name:COMMUNITY COUNSELING SERVICES CHILD COUNSELOR A PROF CORP DEAN HADDOCK
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING SERVICES CHILD COUNSELOR A PROF CORP DEAN HADDOCK
Other - Org Name:LIC MARRIAGE &
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MCCOY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:HADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:661-326-8167
Mailing Address - Street 1:PO BOX 82096
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93380-2096
Mailing Address - Country:US
Mailing Address - Phone:661-326-8167
Mailing Address - Fax:661-326-8221
Practice Address - Street 1:4900 CALIFORNIA AVE
Practice Address - Street 2:330-B
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-7024
Practice Address - Country:US
Practice Address - Phone:661-326-8167
Practice Address - Fax:661-326-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8536103TB0200X, 103TC0700X, 103TC2200X, 103TF0200X, 103TH0100X, 103TM1800X, 103TP0016X, 103TP2701X
CAMI 13954106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8536Medicare ID - Type Unspecified