Basic Information
| Provider Information | |||||||||
| NPI: | 1346463353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORNERSTONE COMMUNITY COUNSELING CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 609 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | IMBODEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724349099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708691500 | ||||||||
| FaxNumber: | 8708691505 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | IMBODEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724349099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708691500 | ||||||||
| FaxNumber: | 8708691505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8708691500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MRC, LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 164272526 | 05 | AR | MEDICAID | 172732526 | 05 | AR | MEDICAID |