Provider Demographics
NPI:1700390374
Name:COMMUNITY COUNSELING & EVALUATION SERVICES, LLC
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING & EVALUATION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-728-1125
Mailing Address - Street 1:125 E WOOLCOCK ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1234
Mailing Address - Country:US
Mailing Address - Phone:920-728-1125
Mailing Address - Fax:
Practice Address - Street 1:115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1631
Practice Address - Country:US
Practice Address - Phone:920-728-1125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6752-123261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1851710909OtherINDIVIDUAL