Provider Demographics
NPI:1629001896
Name:SUPPORTONE INC
Entity Type:Organization
Organization Name:SUPPORTONE INC
Other - Org Name:COMMUNITY-BASED SERVICES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:PETTUS
Authorized Official - Last Name:SCARBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:804-340-1845
Mailing Address - Street 1:2100 W LABUMUM AVE
Mailing Address - Street 2:SUITE 104-B
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227
Mailing Address - Country:US
Mailing Address - Phone:804-340-1845
Mailing Address - Fax:804-340-1848
Practice Address - Street 1:3500 KENSINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-2144
Practice Address - Country:US
Practice Address - Phone:804-342-7366
Practice Address - Fax:804-342-7368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA323101YM0800X
VA323-01-0001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004948271Medicaid