Provider Demographics
NPI:1881495463
Name:CANOPY SUPPORTIVE SERVICES
Entity type:Organization
Organization Name:CANOPY SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-570-4673
Mailing Address - Street 1:955 N 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-1503
Mailing Address - Country:US
Mailing Address - Phone:402-570-4673
Mailing Address - Fax:402-884-9018
Practice Address - Street 1:955 N 28TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-1503
Practice Address - Country:US
Practice Address - Phone:402-570-4673
Practice Address - Fax:402-884-9018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities