Provider Demographics
NPI:1649569625
Name:CORRIDOR CHRISTIAN COUNSELING CENTER
Entity Type:Organization
Organization Name:CORRIDOR CHRISTIAN COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:M S LMFT
Authorized Official - Phone:319-321-9253
Mailing Address - Street 1:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-0667
Mailing Address - Country:US
Mailing Address - Phone:319-665-2137
Mailing Address - Fax:
Practice Address - Street 1:655 LIBERTY WAY STE 6
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9154
Practice Address - Country:US
Practice Address - Phone:319-665-2137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00228251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0115642Medicaid