Provider Demographics
NPI:1730633207
Name:COMMUNITY COUNSELING CENTER
Entity type:Organization
Organization Name:COMMUNITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:STATLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-543-7969
Mailing Address - Street 1:1129 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3323
Mailing Address - Country:US
Mailing Address - Phone:805-543-7969
Mailing Address - Fax:
Practice Address - Street 1:1129 MARSH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3323
Practice Address - Country:US
Practice Address - Phone:805-543-7969
Practice Address - Fax:805-543-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health