Healthcare Provider Details

I. General information

NPI: 1821386855
Provider Name (Legal Business Name): OUTREACH PSYCHIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CONSTITUTION BLVD STE 203
LAWRENCEVILLE GA
30046-8432
US

IV. Provider business mailing address

250 CONSTITUTION BLVD STE 203
LAWRENCEVILLE GA
30046-8432
US

V. Phone/Fax

Practice location:
  • Phone: 770-265-2772
  • Fax: 866-876-7892
Mailing address:
  • Phone: 770-265-2772
  • Fax: 866-876-7892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TAREN LAZZARI
Title or Position: VICE PRESIDENT
Credential: APRN, BC
Phone: 770-265-2772