Basic Information
| Provider Information | |||||||||
| NPI: | 1265164875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUT THE BLUE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 SAINT CLAIR DR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046252841 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 CONCOURSE PKWY | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4708277356 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2022 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | DEW | ||||||||
| AuthorizedOfficialFirstName: | DOMINIQUE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4046252841 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.