Basic Information
Provider Information | |||||||||
NPI: | 1477909810 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY CLINICAL SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CCS BEHAVIORAL AT REN SCHOOL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 95000 LBX 7660 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191950001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077778202 | ||||||||
FaxNumber: | 2077836660 | ||||||||
Practice Location | |||||||||
Address1: | 15 SACRED HEART PL | ||||||||
Address2: | ROOM A | ||||||||
City: | AUBURN | ||||||||
State: | ME | ||||||||
PostalCode: | 042104938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077774175 | ||||||||
FaxNumber: | 2077862221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2016 | ||||||||
LastUpdateDate: | 10/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELIAS | ||||||||
AuthorizedOfficialFirstName: | COLEEN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
AuthorizedOfficialTelephone: | 2075133897 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY CLINICAL SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.