Provider Demographics
NPI:1659676377
Name:COMMUNITY SUPPORT PROFESSIONALS,LLC
Entity Type:Organization
Organization Name:COMMUNITY SUPPORT PROFESSIONALS,LLC
Other - Org Name:TARGETED CASE MANAGMENT: TCM-MH/SA
Other - Org Type:Other Name
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CREECH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-799-4505
Mailing Address - Street 1:1606 WELLINGTON AVE UNIT C
Mailing Address - Street 2:COMMUNITY SUPPORT PROFESSIONALS,LLC
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 UNIT C
Practice Address - Street 2:COMMUNITY SUPPORT PROFESSIONALS,LLC
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:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3410026251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3410026Medicaid