Provider Demographics
NPI:1477052058
Name:THE COMMUNITY COUNSELING & HOUSING SERVICES
Entity Type:Organization
Organization Name:THE COMMUNITY COUNSELING & HOUSING SERVICES
Other - Org Name:THE PETROVA HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:EDS, EDD, RADC-P
Authorized Official - Phone:314-580-3029
Mailing Address - Street 1:4166 LINDELL BLVD APT 1B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2923
Mailing Address - Country:US
Mailing Address - Phone:314-580-3029
Mailing Address - Fax:
Practice Address - Street 1:2407 PETROVA AVE
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:MO
Practice Address - Zip Code:63136-3903
Practice Address - Country:US
Practice Address - Phone:314-580-3029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy