Provider Demographics
NPI:1649577453
Name:SAMPLE SUPPORTS
Entity Type:Organization
Organization Name:SAMPLE SUPPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:720-684-6102
Mailing Address - Street 1:606 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2779
Mailing Address - Country:US
Mailing Address - Phone:720-684-6102
Mailing Address - Fax:303-261-8216
Practice Address - Street 1:606 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2779
Practice Address - Country:US
Practice Address - Phone:720-684-6102
Practice Address - Fax:303-261-8216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40078256Medicaid