Basic Information
| Provider Information | |||||||||
| NPI: | 1407585706 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA OUTREACH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5108 REAGAN DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282063103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043328787 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5108 REAGAN DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282063103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043328787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2022 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTENSIVE IN-HOME THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7045659538 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
| NPICertificationDate: | 06/10/2022 | ||||||||
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.