Provider Demographics
NPI:1588876932
Name:PROVIDENCE SUPPORT SERVICES INC.
Entity type:Organization
Organization Name:PROVIDENCE SUPPORT SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF QUALITY ASSURANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RODDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:505-898-9435
Mailing Address - Street 1:8328 CALLE PRIMERA NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5386
Mailing Address - Country:US
Mailing Address - Phone:505-898-9435
Mailing Address - Fax:505-898-9052
Practice Address - Street 1:8328 CALLE PRIMERA NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-5386
Practice Address - Country:US
Practice Address - Phone:505-898-9435
Practice Address - Fax:505-898-9052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM68929072320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68929072OtherPROVIDER NUMBER