Provider Demographics
NPI:1356590806
Name:MOUNTAIN COMMUNITY COUNSELING
Entity type:Organization
Organization Name:MOUNTAIN COMMUNITY COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:BERRIE
Authorized Official - Last Name:CARMACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-281-9542
Mailing Address - Street 1:12064 HWY 14 N
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9405
Mailing Address - Country:US
Mailing Address - Phone:505-281-9542
Mailing Address - Fax:505-281-9567
Practice Address - Street 1:12064 HWY 14 N
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9405
Practice Address - Country:US
Practice Address - Phone:505-281-9542
Practice Address - Fax:505-281-9567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT0113761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty