Provider Demographics
NPI:1629434451
Name:CLINICAL COMMUNITY SOLUTIONS LLC
Entity Type:Organization
Organization Name:CLINICAL COMMUNITY SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:585-975-9216
Mailing Address - Street 1:4312 WATERFORD VALLEY DR
Mailing Address - Street 2:SUITE 1321
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-8342
Mailing Address - Country:US
Mailing Address - Phone:585-975-9216
Mailing Address - Fax:
Practice Address - Street 1:4312 WATERFORD VALLEY DR
Practice Address - Street 2:SUITE 1321
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8342
Practice Address - Country:US
Practice Address - Phone:585-975-9216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9058251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538415682OtherPERSONAL NPI NUMBER