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General NPI Number Information
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NPI Number | 1578893699
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Entity Type | Organization
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Legal Business Name | GROUP HOME SUPPORT SERVICES
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Dates
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Enumeration Date | 01/12/2010
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Last Update Date | 05/25/2011
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Provider Practice Location Address
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Address Line | 245 NORTH MURRAY STREET
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City | BANNING
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State | CA
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Zip | 92220-5528
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Country | US
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Telephone | 951-849-8812
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Fax | 951-755-8915
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Provider Business Mailing Address
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Address Line | 245 NORTH MURRAY STREET
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City | BANNING
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State | CA
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Zip | 92220-5528
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Country | US
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Telephone | 951-849-8812
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Fax | 951-755-8915
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. SHARON HEASTON
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Credential | MFT
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Telephone | 909-224-3942
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 261QMO801X
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License Number State | CA
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