Provider Demographics
NPI:1952556755
Name:COMMUNITY COUNSELING CENTER OF NORTHERN MADISON COUNTY
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CENTER OF NORTHERN MADISON COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOPRONYI-TOMPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-4883
Mailing Address - Street 1:2615 EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3915
Mailing Address - Country:US
Mailing Address - Phone:618-462-2331
Mailing Address - Fax:
Practice Address - Street 1:2615 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3915
Practice Address - Country:US
Practice Address - Phone:618-462-2331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid