Provider Demographics
NPI:1053441113
Name:CSP
Entity Type:Organization
Organization Name:CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR II
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIN
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:949-285-6477
Mailing Address - Street 1:65 FLEURANCE ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-9021
Mailing Address - Country:US
Mailing Address - Phone:949-285-6477
Mailing Address - Fax:
Practice Address - Street 1:980 CATALINA
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2748
Practice Address - Country:US
Practice Address - Phone:949-285-6477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CSP COMMUNITY SERVICE PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-07
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48267322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children