Provider Demographics
NPI:1942337076
Name:COMMUNITY COUNSELING CLINIC LLC
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR SR MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-452-6546
Mailing Address - Street 1:PO BOX 3036
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-0036
Mailing Address - Country:US
Mailing Address - Phone:509-452-6546
Mailing Address - Fax:509-452-6965
Practice Address - Street 1:2642 MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1752
Practice Address - Country:US
Practice Address - Phone:509-452-6546
Practice Address - Fax:509-452-6965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7500COOtherREGENCE BLUE SHIELD
WACP00002903OtherDARRELL G FRIES CDP
WAA7570OtherPREMERA BLUE CROSS
WA1995448Medicaid