Provider Demographics
NPI:1619276839
Name:COMMUNITY SUPPORT NETWORK
Entity Type:Organization
Organization Name:COMMUNITY SUPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-321-7788
Mailing Address - Street 1:2749 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8723
Mailing Address - Country:US
Mailing Address - Phone:727-321-7788
Mailing Address - Fax:727-327-7187
Practice Address - Street 1:2749 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8723
Practice Address - Country:US
Practice Address - Phone:727-321-7788
Practice Address - Fax:727-327-7187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL671069768Medicaid
FL671069796Medicaid
FL671069798Medicaid