Organization
COMMUNITY COUNSELING CENTERS INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. IVAN ROBERT WILDERMAN PH D (CHIEF EXECUTIVE OFFICER)
(928) 624-6701
Entity
Organization
Contact information
Practice address
211 EAST THIRD STREET, WINSLOW, AZ 86047-3802
(928) 289-4658
(928) 289-3775
Mailing address
211 EAST THIRD STREET, WINSLOW, AZ 86047-3802
(928) 289-4658
(928) 289-3775
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
BH141
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
007452
AHCCCS
AZ
Enumeration date
06/08/2006
Last updated
08/22/2020
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