Basic Information
| Provider Information | |||||||||
| NPI: | 1871172429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCF MENTAL HEALTH CONSULTATION PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2022 S WEBB RD STE 261 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672075627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162582409 | ||||||||
| FaxNumber: | 3162850527 | ||||||||
| Practice Location | |||||||||
| Address1: | 9415 E HARRY ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672075077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162582409 | ||||||||
| FaxNumber: | 3162850527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2021 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | FULFORD | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | COLLEEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3162582409 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LSCSW, LCAC | ||||||||
| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.