=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649452251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY NETWORK AND FELLOW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2007
-----------------------------------------------------
Last Update Date | 12/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14019 N 149TH DR
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85379-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-533-1689
-----------------------------------------------------
Fax | 623-547-6210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14019 N 149TH DR
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85379-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-533-1689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FACULTY ADMINISTRATOR
-----------------------------------------------------
Name | KISHA BERNICE SPELLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-533-1689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | BH2872
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------