Provider Demographics
NPI:1992828966
Name:COMMUNITY SUPPORT NETWORK
Entity Type:Organization
Organization Name:COMMUNITY SUPPORT NETWORK
Other - Org Name:CSN DUTTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE ADMIN.
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:707-575-0979
Mailing Address - Street 1:1410 GUERNEVILLE RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:94503
Mailing Address - Country:US
Mailing Address - Phone:707-575-0979
Mailing Address - Fax:707-573-6968
Practice Address - Street 1:1550 N. DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:707-573-6962
Practice Address - Fax:707-573-6967
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY SUPPORT NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-06
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490111656320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities