Provider Demographics
NPI:1023093473
Name:COMPLEMENTARY SUPPORT SERVICES
Entity type:Organization
Organization Name:COMPLEMENTARY SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DIMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:952-608-8403
Mailing Address - Street 1:6701 PENN AVENUE S.
Mailing Address - Street 2:SUITE #301
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423
Mailing Address - Country:US
Mailing Address - Phone:952-608-8403
Mailing Address - Fax:612-861-7589
Practice Address - Street 1:6701 PENN AVE S
Practice Address - Street 2:SUITE #301
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2093
Practice Address - Country:US
Practice Address - Phone:952-608-8403
Practice Address - Fax:612-861-7589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN088791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04098Medicare ID - Type UnspecifiedGROUP