Organization
COMMUNITY COUNSELING CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CAROLYN KAY FRIES (ADMINISTRATOR SR MEMBER)
(509) 452-6546
Entity
Organization
Contact information
Practice address
2642 MAIN ST, UNION GAP, WA 98903-1752
(509) 452-6546
(509) 452-6965
Mailing address
PO BOX 3036, UNION GAP, WA 98903-0036
(509) 452-6546
(509) 452-6965
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1995448
—
WA
01
—
7500CO
REGENCE BLUE SHIELD
WA
01
—
A7570
PREMERA BLUE CROSS
WA
01
—
CP00002903
DARRELL G FRIES CDP
WA
Enumeration date
02/27/2007
Last updated
08/22/2020
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