=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568885382
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTIONS COMMUNITY SUPPORT PROGRAMS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2014
-----------------------------------------------------
Last Update Date | 01/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W 10TH ST
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19801-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-672-9360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 W 10TH STREET
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-672-9360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MR. CHRIS DEVANEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 302-230-9102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC-0000659
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------