Healthcare Provider Details

I. General information

NPI: 1871257964
Provider Name (Legal Business Name): OUTREACH RECOVERY II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HOSPITAL RD STE 306
PRINCE FREDERICK MD
20678-4046
US

IV. Provider business mailing address

14205 PARK CENTER DR # 201202
LAUREL MD
20707-5246
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 TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GINNY HAYDEN
Title or Position: LICENSING MANAGER
Credential:
Phone: 240-728-5864