Healthcare Provider Details

I. General information

NPI: 1982289062
Provider Name (Legal Business Name): TEEN OUT REACH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 S 96TH PL
MESA AZ
85208-2512
US

IV. Provider business mailing address

544 S 96TH PL APT 2080
MESA AZ
85208-2512
US

V. Phone/Fax

Practice location:
  • Phone: 480-696-0338
  • Fax:
Mailing address:
  • Phone: 480-696-0338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number State

VIII. Authorized Official

Name: AMANDA REANE JOHNSON
Title or Position: DIRECTOR
Credential: MD
Phone: 480-696-0338