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General NPI Number Information
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NPI Number | 1154340396
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Entity Type | Organization
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Legal Business Name | CG-DSA, LLC
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 08/13/2021
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Provider Practice Location Address
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Address Line | 1313 HOMEWOOD DRIVE
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City | CRAWFORDSVILLE
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State | IN
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Zip | 47933-3341
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Country | US
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Telephone | 765-362-0905
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Fax |
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Provider Business Mailing Address
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Address Line | 4800 OVERTON PLAZA
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City | FORT WORTH
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State | TX
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Zip | 76109-4435
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Country | US
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Telephone | 800-299-5161
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Fax |
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Authorized Official
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Title or Position | OPERATIONS BUSINESS MANAGER
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Name | ANNA TODD
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Credential |
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Telephone | 800-299-5161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 0683I0001JN08
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 0683I0002JN08
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 0683I0003JN08
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 0683I0004JN08
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License Number State | IN
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Taxonomy #5
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 0683I0005JN08
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License Number State | IN
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Taxonomy #6
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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