Provider Demographics
NPI:1285892208
Name:COMMUNITY COUNSELING CENTER OF MERCER COUNTY
Entity type:Organization
Organization Name:COMMUNITY COUNSELING CENTER OF MERCER COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:STAMOOLIS
Authorized Official - Suffix:
Authorized Official - Credentials:M ED
Authorized Official - Phone:724-981-7141
Mailing Address - Street 1:2201 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-2727
Mailing Address - Country:US
Mailing Address - Phone:724-981-7141
Mailing Address - Fax:724-981-7763
Practice Address - Street 1:77 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-1781
Practice Address - Country:US
Practice Address - Phone:724-588-6490
Practice Address - Fax:724-588-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA437028261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100000380Medicaid