Provider Demographics
NPI:1417344896
Name:COMMUNITY COUNSELING & MENTORING SERVICES, INC.
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING & MENTORING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARVANA
Authorized Official - Suffix:SR
Authorized Official - Credentials:MA
Authorized Official - Phone:301-583-0001
Mailing Address - Street 1:1300 MERCANTILE LN
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5327
Mailing Address - Country:US
Mailing Address - Phone:301-583-0001
Mailing Address - Fax:
Practice Address - Street 1:1300 MERCANTILE LN
Practice Address - Street 2:SUITE 208
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5327
Practice Address - Country:US
Practice Address - Phone:301-583-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD100445261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder