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General NPI Number Information
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NPI Number | 1396954087
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Entity Type | Organization
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Legal Business Name | COMMUNITY SUPPORT NETWORK
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 21 FAYE CT
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City | PETALUMA
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State | CA
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Zip | 94952-2202
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Country | US
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Telephone | 707-765-0102
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Fax | 707-765-0124
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Provider Business Mailing Address
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Address Line | 21 FAYE CT
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City | PETALUMA
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State | CA
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Zip | 94952-2202
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Country | US
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Telephone | 707-765-0102
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Fax | 707-765-0124
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Authorized Official
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Title or Position | PROGRAM MANAGER
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Name | MS. ALLISON BALL
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Credential |
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Telephone | 707-765-0102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State | CA
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