Healthcare Provider Details

I. General information

NPI: 1255656609
Provider Name (Legal Business Name): COMMUNITY SUPPORT NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3595 SULLIVANT AVE
COLUMBUS OH
43228-2121
US

IV. Provider business mailing address

3595 SULLIVANT AVE
COLUMBUS OH
43228-2121
US

V. Phone/Fax

Practice location:
  • Phone: 614-752-0333
  • Fax: 614-995-3268
Mailing address:
  • Phone: 614-752-0333
  • Fax: 614-995-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberI 0007788
License Number StateOH

VIII. Authorized Official

Name: MR. ROBERT SHORT
Title or Position: CEO
Credential:
Phone: 614-752-0333