Basic Information
| Provider Information | |||||||||
| NPI: | 1831219989 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY SUPPPORT NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1410 GUERNEVILLE RD | ||||||||
| Address2: | 14 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954037231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075750979 | ||||||||
| FaxNumber: | 7075736968 | ||||||||
| Practice Location | |||||||||
| Address1: | 634 PRESSLEY ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954045526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075736955 | ||||||||
| FaxNumber: | 7075438176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 06/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | LARSON | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF SOCIAL REHABILITATION | ||||||||
| AuthorizedOfficialTelephone: | 7075750979 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.