Provider Demographics
NPI:1922133164
Name:COMMUNITY CLINIC, INC
Entity Type:Organization
Organization Name:COMMUNITY CLINIC, INC
Other - Org Name:CCI
Other - Org Type:Other Name
Authorized Official - Title/Position:PHD.PSY.D- CLINICAL PSYCHOLOGISTCEO
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-839-5107
Mailing Address - Street 1:8665 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3405
Mailing Address - Country:US
Mailing Address - Phone:301-340-7525
Mailing Address - Fax:301-495-0318
Practice Address - Street 1:8630 FENTON ST STE 1200
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3808
Practice Address - Country:US
Practice Address - Phone:301-585-1250
Practice Address - Fax:301-585-6289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD130061003Medicaid
MD053601Medicare ID - Type Unspecified