1942337076 NPI number — COMMUNITY COUNSELING CLINIC LLC

Table of content: (NPI 1942337076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942337076 NPI number — COMMUNITY COUNSELING CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY COUNSELING CLINIC 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:
1942337076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNION GAP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98903-0036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-452-6546
Provider Business Mailing Address Fax Number:
509-452-6965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2642 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNION GAP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98903-1752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-452-6546
Provider Business Practice Location Address Fax Number:
509-452-6965
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FRIES
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
ADMINISTRATOR SR MEMBER
Authorized Official Telephone Number:
509-452-6546

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7500CO . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CP00002903 . This is a "DARRELL G FRIES CDP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: A7570 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1995448 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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