Provider Demographics
NPI:1114256906
Name:COMMUNITY SUPPORT PROFESSIONALS,LLC
Entity Type:Organization
Organization Name:COMMUNITY SUPPORT PROFESSIONALS,LLC
Other - Org Name:CSP ACT TEAM SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:JUSTAFORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-799-4505
Mailing Address - Street 1:1606 WELLINGTON AVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7704
Mailing Address - Country:US
Mailing Address - Phone:910-799-4505
Mailing Address - Fax:910-799-4345
Practice Address - Street 1:1606 WELLINGTON AVE
Practice Address - Street 2:UNIT F
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7704
Practice Address - Country:US
Practice Address - Phone:910-799-4505
Practice Address - Fax:910-799-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8300728A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300728AMedicaid