Provider Demographics
NPI:1427272004
Name:COMMUNITY SUPPORT NETWORK
Entity type:Organization
Organization Name:COMMUNITY SUPPORT NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-575-0979
Mailing Address - Street 1:1410 GUERNEVILLE RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7231
Mailing Address - Country:US
Mailing Address - Phone:707-575-0979
Mailing Address - Fax:707-573-6968
Practice Address - Street 1:112 BROWN ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5007
Practice Address - Country:US
Practice Address - Phone:707-568-5204
Practice Address - Fax:707-575-3315
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY SUPPORT NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496801902320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness