Basic Information
| Provider Information | |||||||||
| NPI: | 1922431089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA OUTREACH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285014933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102987167 | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 S QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285014933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102987167 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2013 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9192519001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 3410049 | NC | Y | Agencies | Community/Behavioral Health |
No ID Information.