Provider Demographics
NPI:1750767257
Name:COMMUNITY LIVING SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:COMMUNITY LIVING SUPPORT SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSEE DESIGNEE, ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:517-554-8788
Mailing Address - Street 1:6929 CALHOUN RD
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-9651
Mailing Address - Country:US
Mailing Address - Phone:517-554-8788
Mailing Address - Fax:517-465-7103
Practice Address - Street 1:6929 CALHOUN RD
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:MI
Practice Address - Zip Code:49224-9651
Practice Address - Country:US
Practice Address - Phone:517-554-8788
Practice Address - Fax:517-465-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS130374875251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health