Provider Demographics
NPI: | 1952443467 |
---|---|
Name: | CORNERSTONE CHRISTIAN COUNSELING |
Entity Type: | Organization |
Organization Name: | CORNERSTONE CHRISTIAN COUNSELING |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | LICENSED PSYCHOTHERAPIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | ANDREA |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | RUSSELL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHD |
Authorized Official - Phone: | 520-885-0557 |
Mailing Address - Street 1: | 7660 E BROADWAY BLVD |
Mailing Address - Street 2: | SUITE 207 |
Mailing Address - City: | TUCSON |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85710-3774 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 520-885-0557 |
Mailing Address - Fax: | 520-885-1157 |
Practice Address - Street 1: | 7660 E BROADWAY BLVD |
Practice Address - Street 2: | SUITE 207 |
Practice Address - City: | TUCSON |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85710-3774 |
Practice Address - Country: | US |
Practice Address - Phone: | 520-885-0557 |
Practice Address - Fax: | 520-885-1157 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-02-12 |
Last Update Date: | 2012-10-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | AZ LPC 1342 | 103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TM1800X, 103TP2701X, 246ZE0500X, 2472E0500X |
AZ | AZ LPC 1342 | 103TC1900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | Group - Multi-Specialty |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family | Group - Multi-Specialty |
No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities | Group - Multi-Specialty |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
No | 246ZE0500X | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | EEG | Group - Multi-Specialty |
No | 2472E0500X | Technologists, Technicians & Other Technical Service Providers | Technician, Other | EEG | Group - Multi-Specialty |