Provider Demographics
NPI:1720029622
Name:COMMUNITY COUNSELING CENTER OF ASHTABULA COUNTY
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CENTER OF ASHTABULA COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:BOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:MS,ED,LPCC-S, CDCA
Authorized Official - Phone:440-998-4210
Mailing Address - Street 1:2801 'C' COURT
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004
Mailing Address - Country:US
Mailing Address - Phone:440-998-4210
Mailing Address - Fax:440-998-2247
Practice Address - Street 1:2801 C CT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4577
Practice Address - Country:US
Practice Address - Phone:440-998-4210
Practice Address - Fax:440-998-2247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0166251B00000X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251B00000XAgenciesCase Management
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0200508Medicaid
OH000000003392Medicare UPIN
OH9183253Medicare ID - Type Unspecified