Provider Demographics
NPI:1700264918
Name:COMMONWEALTH COUNSELING CENTERS LLC
Entity Type:Organization
Organization Name:COMMONWEALTH COUNSELING CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:DORSEY
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:IV
Authorized Official - Credentials:MED,LCADC, CSS
Authorized Official - Phone:606-506-5077
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653
Mailing Address - Country:US
Mailing Address - Phone:606-506-5077
Mailing Address - Fax:
Practice Address - Street 1:156 N LAKE DR
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1270
Practice Address - Country:US
Practice Address - Phone:606-506-5077
Practice Address - Fax:606-506-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1361324500000X
KY810470324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100436100Medicaid