Healthcare Provider Details

I. General information

NPI: 1780610923
Provider Name (Legal Business Name): COMMUNITY SERVICE ASSOCIATES, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 HUNTERS TRL
PORTAGE WI
53901-3403
US

IV. Provider business mailing address

PO BOX 301 2901 HUNTERS TRAIL
PORTAGE WI
53901-3403
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-5518
  • Fax: 608-742-4087
Mailing address:
  • Phone: 608-742-5518
  • Fax: 608-742-4087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2149
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHERRY D STEVENS
Title or Position: CREDENTIALING DEPT/BUSINESS MANAGER
Credential:
Phone: 608-742-5518