Provider Demographics
NPI:1972623833
Name:COMMUNITY COUNSELING CENTER, LTD.
Entity type:Organization
Organization Name:COMMUNITY COUNSELING CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-338-7749
Mailing Address - Street 1:666 RUSSEL CT
Mailing Address - Street 2:105
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2670
Mailing Address - Country:US
Mailing Address - Phone:815-338-7749
Mailing Address - Fax:815-338-7728
Practice Address - Street 1:666 RUSSEL CT
Practice Address - Street 2:105
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2670
Practice Address - Country:US
Practice Address - Phone:815-338-7749
Practice Address - Fax:815-338-7728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05630307OtherBCBS
IL05630307OtherBCBS