Provider Demographics
NPI:1407298276
Name:CROSS CREEK COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:CROSS CREEK COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-260-5228
Mailing Address - Street 1:320 ICHORD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3600
Mailing Address - Country:US
Mailing Address - Phone:573-774-5800
Mailing Address - Fax:314-255-1856
Practice Address - Street 1:320 ICHORD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3600
Practice Address - Country:US
Practice Address - Phone:573-774-5800
Practice Address - Fax:314-255-1856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002001101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty