Provider Demographics
NPI:1609657766
Name:CENTER STREET COMMUNITY CLINIC, INC
Entity Type:Organization
Organization Name:CENTER STREET COMMUNITY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-751-4531
Mailing Address - Street 1:136 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-3704
Mailing Address - Country:US
Mailing Address - Phone:740-751-4531
Mailing Address - Fax:
Practice Address - Street 1:125 EXECUTIVE DR STE 201
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6302
Practice Address - Country:US
Practice Address - Phone:740-387-3087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty