Provider Demographics
NPI:1760503197
Name:PUBLIC CHARTER SCHOOL CENTER FOR STUDENT SUPPORT SERVICES
Entity Type:Organization
Organization Name:PUBLIC CHARTER SCHOOL CENTER FOR STUDENT SUPPORT SERVICES
Other - Org Name:STUDENT SUPPORT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:202-628-8848
Mailing Address - Street 1:1003 K ST NW
Mailing Address - Street 2:SUITE 405
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-4425
Mailing Address - Country:US
Mailing Address - Phone:202-628-8848
Mailing Address - Fax:202-628-8849
Practice Address - Street 1:1003 K ST NW
Practice Address - Street 2:SUITE 405
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-4425
Practice Address - Country:US
Practice Address - Phone:202-628-8848
Practice Address - Fax:202-628-8849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC036394400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036394400Medicaid