Basic Information
Provider Information | |||||||||
NPI: | 1184834277 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKLIN COMMUNITY COUNSELING CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4240 ROCKLIN RD | ||||||||
Address2: | SUITE 5 | ||||||||
City: | ROCKLIN | ||||||||
State: | CA | ||||||||
PostalCode: | 956772862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9163150468 | ||||||||
FaxNumber: | 9163150462 | ||||||||
Practice Location | |||||||||
Address1: | 4240 ROCKLIN RD STE 5 | ||||||||
Address2: | SUITE 5 | ||||||||
City: | ROCKLIN | ||||||||
State: | CA | ||||||||
PostalCode: | 956772862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9163150468 | ||||||||
FaxNumber: | 9163150462 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | O'SULLIVAN | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9163150468 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 310009DN | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.