Provider Demographics
NPI:1831219989
Name:COMMUNITY SUPPPORT NETWORK
Entity type:Organization
Organization Name:COMMUNITY SUPPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SOCIAL REHABILITATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-575-0979
Mailing Address - Street 1:1410 GUERNEVILLE RD
Mailing Address - Street 2:14
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7231
Mailing Address - Country:US
Mailing Address - Phone:707-575-0979
Mailing Address - Fax:707-573-6968
Practice Address - Street 1:634 PRESSLEY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5526
Practice Address - Country:US
Practice Address - Phone:707-573-6955
Practice Address - Fax:707-543-8176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness