Healthcare Provider Details

I. General information

NPI: 1336563725
Provider Name (Legal Business Name): COMMUNITY SUPPORT NETWORK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1191 N SHERMAN AVE
MADISON WI
53704-4234
US

IV. Provider business mailing address

1137 N SHERMAN AVE
MADISON WI
53704-4234
US

V. Phone/Fax

Practice location:
  • Phone: 608-421-3239
  • Fax: 608-270-2238
Mailing address:
  • Phone: 608-421-3239
  • Fax: 608-270-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. DEBORAH KORSOWER RAETTIG
Title or Position: EXECUTIVE DIRECTOR
Credential: MSSW
Phone: 608-421-3239