Provider Demographics
NPI:1295251437
Name:COORDINATED COUNSELING FOR CHILDREN
Entity type:Organization
Organization Name:COORDINATED COUNSELING FOR CHILDREN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WISDOM-IMBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:303-946-9071
Mailing Address - Street 1:295 CHURCH ST SE APT 305
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3832
Mailing Address - Country:US
Mailing Address - Phone:303-946-9071
Mailing Address - Fax:
Practice Address - Street 1:528 COTTAGE ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3811
Practice Address - Country:US
Practice Address - Phone:303-946-9071
Practice Address - Fax:267-288-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3841101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty