Provider Demographics
NPI:1265711642
Name:CHURCH COUNSELING SERVICE INC
Entity type:Organization
Organization Name:CHURCH COUNSELING SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FORT
Authorized Official - Suffix:
Authorized Official - Credentials:MA MFT
Authorized Official - Phone:909-982-8687
Mailing Address - Street 1:188 W LANGSTON ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3123
Mailing Address - Country:US
Mailing Address - Phone:909-982-8687
Mailing Address - Fax:
Practice Address - Street 1:188 W LANGSTON ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3123
Practice Address - Country:US
Practice Address - Phone:909-982-8687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMF013902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty