Basic Information
| Provider Information | |||||||||
| NPI: | 1275807653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUTLOOK FORENSIC & BEHAVIORAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OUTLOOK BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14636 REESE BLVD W | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048413886 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2012 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | STOUDMIRE | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7048413886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OUTLOOK FORENSIC & BEHAVIORAL HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.