Provider Demographics
NPI:1578008546
Name:COMMUNITY SUPPORT SERVICES, INC.
Entity Type:Organization
Organization Name:COMMUNITY SUPPORT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAVELINE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MHA, BCBA-D
Authorized Official - Phone:301-926-2300
Mailing Address - Street 1:9075 COMPRINT CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1306
Mailing Address - Country:US
Mailing Address - Phone:301-926-2300
Mailing Address - Fax:
Practice Address - Street 1:9075 COMPRINT CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1306
Practice Address - Country:US
Practice Address - Phone:301-926-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0179320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1609915495Medicaid