Basic Information
| Provider Information | |||||||||
| NPI: | 1518110139 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA OUTREACH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2670 DURHAM CHAPEL HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277072829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192519001 | ||||||||
| FaxNumber: | 9192519008 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 REGENT PARK BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288063727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285051762 | ||||||||
| FaxNumber: | 8285051763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | BURGESS-JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLOW | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, CAROLINA OUTREACH WEST | ||||||||
| AuthorizedOfficialTelephone: | 8285051762 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6006593 | 05 | NC | MEDICAID |