Provider Demographics
NPI:1487679973
Name:COMMUNITY COUNSELING CENTERS INC
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CENTERS INC
Other - Org Name:PINE VIEW BEHAVIORAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WILDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-524-6701
Mailing Address - Street 1:2550 SHOW LOW LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7929
Mailing Address - Country:US
Mailing Address - Phone:928-537-1029
Mailing Address - Fax:928-537-9049
Practice Address - Street 1:2550 SHOW LOW LAKE ROAD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7929
Practice Address - Country:US
Practice Address - Phone:928-537-1029
Practice Address - Fax:928-537-9049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ590142OtherAHCCCS