Basic Information
| Provider Information | |||||||||
| NPI: | 1285054692 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA OUTREACH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 WILKINS ST STE D&E | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192519001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 S BRIGHTLEAF BLVD | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192519001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | ROB | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMIN SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 9192519001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 101YM0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.