Provider Demographics
NPI:1417397209
Name:COMMUNITY COUNSELING SERVICES OF MISSOURI, L.L.C.
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING SERVICES OF MISSOURI, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:417-260-7707
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:15423 MCCLOY ROAD
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-0111
Mailing Address - Country:US
Mailing Address - Phone:417-260-7707
Mailing Address - Fax:
Practice Address - Street 1:15423 MCCLOY ROAD
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-0111
Practice Address - Country:US
Practice Address - Phone:417-260-7707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010040294101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154766806Medicaid