Provider Demographics
NPI:1669413175
Name:COMMUNITY COUNSELING CENTERS INC
Entity type:Organization
Organization Name:COMMUNITY COUNSELING CENTERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WILDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:928-624-6701
Mailing Address - Street 1:211 EAST THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3802
Mailing Address - Country:US
Mailing Address - Phone:928-289-4658
Mailing Address - Fax:928-289-3775
Practice Address - Street 1:211 EAST THIRD STREET
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3802
Practice Address - Country:US
Practice Address - Phone:928-289-4658
Practice Address - Fax:928-289-3775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH141261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ007452OtherAHCCCS