Healthcare Provider Details

I. General information

NPI: 1629876297
Provider Name (Legal Business Name): COMMUNITY SOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 SKYLINE RD NE APT 2723
ALBUQUERQUE NM
87123-3087
US

IV. Provider business mailing address

12021 SKYLINE RD NE APT 2723
ALBUQUERQUE NM
87123-3087
US

V. Phone/Fax

Practice location:
  • Phone: 575-650-0132
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ANNALIZA GOURNEAU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 575-650-0132