Provider Demographics
NPI:1346463353
Name:CORNERSTONE COMMUNITY COUNSELING CORP
Entity Type:Organization
Organization Name:CORNERSTONE COMMUNITY COUNSELING CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MRC, LPC
Authorized Official - Phone:870-869-1500
Mailing Address - Street 1:609 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:IMBODEN
Mailing Address - State:AR
Mailing Address - Zip Code:72434-9099
Mailing Address - Country:US
Mailing Address - Phone:870-869-1500
Mailing Address - Fax:870-869-1505
Practice Address - Street 1:609 W 3RD ST
Practice Address - Street 2:
Practice Address - City:IMBODEN
Practice Address - State:AR
Practice Address - Zip Code:72434-9099
Practice Address - Country:US
Practice Address - Phone:870-869-1500
Practice Address - Fax:870-869-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164272526Medicaid
AR172732526Medicaid
AR5G332Medicare PIN