Healthcare Provider Details

I. General information

NPI: 1457800385
Provider Name (Legal Business Name): OUTREACH NATION, CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9565 BUSINESS CENTER DR STE A
RANCHO CUCAMONGA CA
91730-4560
US

IV. Provider business mailing address

9565 BUSINESS CENTER DR BLDG 11 SUITE A
RANCHO CUCAMONGA CA
91730
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-8080
  • Fax:
Mailing address:
  • Phone: 909-825-8080
  • Fax: 909-292-4532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW28947
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLCSW28841
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFTI60442
License Number StateCA

VIII. Authorized Official

Name: MRS. KHALIDA KHANUM
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 909-825-8080