Provider Demographics
NPI:1932348620
Name:COMMUNITY COUNSELING & MENTORING SERVICES
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING & MENTORING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:810-987-2681
Mailing Address - Street 1:312 SUPERIOR MALL
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3833
Mailing Address - Country:US
Mailing Address - Phone:810-987-2681
Mailing Address - Fax:810-987-2784
Practice Address - Street 1:312 SUPERIOR MALL
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3833
Practice Address - Country:US
Practice Address - Phone:810-987-2681
Practice Address - Fax:810-987-2784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty