1932650058 NPI number — CONCORD COUNSELING CENTER LLC

Table of content: (NPI 1932650058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932650058 NPI number — CONCORD COUNSELING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONCORD COUNSELING CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932650058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
897 TOWNE CENTER DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34759-3469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-530-5206
Provider Business Mailing Address Fax Number:
407-530-5198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
897 TOWNE CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34759-3469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-530-5206
Provider Business Practice Location Address Fax Number:
407-530-5198
Provider Enumeration Date:
10/24/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KLEE
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
407-530-5206

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  10841 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010370700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".