Healthcare Provider Details

I. General information

NPI: 1205447679
Provider Name (Legal Business Name): OUTREACH RECOVERY II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 MIDDLEFORD RD
SEAFORD DE
19973-3650
US

IV. Provider business mailing address

4201 NORTHVIEW DR STE 104
BOWIE MD
20716-2655
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-4466
  • Fax:
Mailing address:
  • Phone: 410-800-4466
  • Fax: 410-705-5024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ISIAH COLES
Title or Position: COO
Credential:
Phone: 561-502-3978