Basic Information
| Provider Information | |||||||||
| NPI: | 1407284524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA OUTREACH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3012 FALSTAFF RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196151027 | ||||||||
| FaxNumber: | 9192519008 | ||||||||
| Practice Location | |||||||||
| Address1: | 3012 FALSTAFF RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196151027 | ||||||||
| FaxNumber: | 9192519008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2013 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9192519001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6005418 | NC | Y | Agencies | Community/Behavioral Health |
No ID Information.