Healthcare Provider Details

I. General information

NPI: 1215593785
Provider Name (Legal Business Name): OUTREACH RECOVERY II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 CRAIN HWY N STE 7B
GLEN BURNIE MD
21061-9304
US

IV. Provider business mailing address

14205 PARK CENTER DR # 201202
LAUREL MD
20707-5246
US

V. Phone/Fax

Practice location:
  • Phone: 561-502-3978
  • Fax:
Mailing address:
  • Phone: 410-800-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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