Provider Demographics
NPI:1396945432
Name:CLINICAL COUNSELING PRACTICE, PLLC
Entity type:Organization
Organization Name:CLINICAL COUNSELING PRACTICE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JIMALEE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:606-495-5478
Mailing Address - Street 1:123 PLEASANT VIEW LN
Mailing Address - Street 2:
Mailing Address - City:EZEL
Mailing Address - State:KY
Mailing Address - Zip Code:41425-8522
Mailing Address - Country:US
Mailing Address - Phone:606-495-5478
Mailing Address - Fax:
Practice Address - Street 1:525 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1015
Practice Address - Country:US
Practice Address - Phone:606-495-5478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3019251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1376698167OtherINDIVIDUAL NPI