Provider Demographics
NPI:1649452251
Name:COMMUNITY NETWORK AND FELLOW
Entity type:Organization
Organization Name:COMMUNITY NETWORK AND FELLOW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACULTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KISHA
Authorized Official - Middle Name:BERNICE
Authorized Official - Last Name:SPELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-533-1689
Mailing Address - Street 1:14019 N 149TH DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-6012
Mailing Address - Country:US
Mailing Address - Phone:623-533-1689
Mailing Address - Fax:
Practice Address - Street 1:14019 N 149TH DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-6012
Practice Address - Country:US
Practice Address - Phone:623-533-1689
Practice Address - Fax:623-547-6210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2872322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children