Provider Demographics
NPI:1487739819
Name:COMMUNITY COUNSELING CLINIC
Entity type:Organization
Organization Name:COMMUNITY COUNSELING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIERL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-258-0668
Mailing Address - Street 1:16725 12TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3001
Mailing Address - Country:US
Mailing Address - Phone:763-473-3692
Mailing Address - Fax:
Practice Address - Street 1:700 TWELVE OAKS CENTER DR
Practice Address - Street 2:STE. 734
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4401
Practice Address - Country:US
Practice Address - Phone:952-258-0668
Practice Address - Fax:612-235-3384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1597103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty