Healthcare Provider Details

I. General information

NPI: 1003431099
Provider Name (Legal Business Name): OUTREACH RECOVERY II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 PEMBROOKE SQ STE 214
WALDORF MD
20603-4808
US

IV. Provider business mailing address

14205 PARK CENTER DR STE 201
LAUREL MD
20707-5252
US

V. Phone/Fax

Practice location:
  • Phone: 877-889-4829
  • Fax:
Mailing address:
  • Phone: 410-800-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

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