Provider Demographics
NPI:1932535184
Name:CRYSTAL LAKE SUPPORTIVE ENVIRONMENTS
Entity Type:Organization
Organization Name:CRYSTAL LAKE SUPPORTIVE ENVIRONMENTS
Other - Org Name:ATTAIN, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA-D
Authorized Official - Phone:407-965-3055
Mailing Address - Street 1:2710 STATEN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4211
Mailing Address - Country:US
Mailing Address - Phone:407-965-3018
Mailing Address - Fax:877-690-2003
Practice Address - Street 1:2710 STATEN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4211
Practice Address - Country:US
Practice Address - Phone:407-965-3018
Practice Address - Fax:877-690-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL671009396Medicaid