Provider Demographics
NPI:1528303823
Name:COLLABORATIVE COUNSELING CENTER
Entity type:Organization
Organization Name:COLLABORATIVE COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE FAMILY THERAPIST/ OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASSIA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:831-588-8032
Mailing Address - Street 1:6001 BUTLER LN STE 206
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-3550
Mailing Address - Country:US
Mailing Address - Phone:831-588-8032
Mailing Address - Fax:831-440-9016
Practice Address - Street 1:6001 BUTLER LN STE 206
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-3550
Practice Address - Country:US
Practice Address - Phone:831-588-8032
Practice Address - Fax:831-440-9016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA286151041C0700X
CA45342106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty