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General NPI Number Information
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NPI Number | 1629876297
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Entity Type | Organization
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Legal Business Name | COMMUNITY SOURCE
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Dates
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Enumeration Date | 03/07/2025
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Last Update Date | 03/07/2025
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Provider Practice Location Address
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Address Line | 12021 SKYLINE RD NE APT 2723
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City | ALBUQUERQUE
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State | NM
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Zip | 87123-3087
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Country | US
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Telephone | 575-650-0132
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Fax |
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Provider Business Mailing Address
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Address Line | 12021 SKYLINE RD NE APT 2723
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City | ALBUQUERQUE
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State | NM
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Zip | 87123-3087
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. ANNALIZA GOURNEAU
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Credential |
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Telephone | 575-650-0132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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