Healthcare Provider Details

I. General information

NPI: 1326464785
Provider Name (Legal Business Name): CAROLINA OUTREACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 SHOTWELL RD
CLAYTON NC
27520-5597
US

IV. Provider business mailing address

935 SHOTWELL RD
CLAYTON NC
27520-5597
US

V. Phone/Fax

Practice location:
  • Phone: 919-251-9001
  • Fax:
Mailing address:
  • Phone: 919-251-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC

VIII. Authorized Official

Name: ROB DAVIS
Title or Position: ADMIN SUPPORT
Credential:
Phone: 919-251-9001