Basic Information
| Provider Information | |||||||||
| NPI: | 1427272004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY SUPPORT NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CSN BROWN ST. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1410 GUERNEVILLE RD | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954037231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075750979 | ||||||||
| FaxNumber: | 7075736968 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 BROWN ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954045007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075685204 | ||||||||
| FaxNumber: | 7075753315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEVITT | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7075750979 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY SUPPORT NETWORK | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 496801902 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.