Provider Demographics
NPI:1780393587
Name:COMMUNITY COUNSELING AND COACHING CENTER
Entity type:Organization
Organization Name:COMMUNITY COUNSELING AND COACHING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:AIKO
Authorized Official - Last Name:DE PACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-274-8317
Mailing Address - Street 1:22700 BEAVERHEAD DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1510
Mailing Address - Country:US
Mailing Address - Phone:909-274-8317
Mailing Address - Fax:
Practice Address - Street 1:22700 BEAVERHEAD DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1510
Practice Address - Country:US
Practice Address - Phone:909-274-8317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty