Healthcare Provider Details

I. General information

NPI: 1720648082
Provider Name (Legal Business Name): TRUE OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 WAKE FOREST BUSINESS PARK STE G
WAKE FOREST NC
27587-7184
US

IV. Provider business mailing address

4215 VIEWMONT DR
RALEIGH NC
27610-5330
US

V. Phone/Fax

Practice location:
  • Phone: 919-306-0809
  • Fax:
Mailing address:
  • Phone: 919-306-0809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11836110
Identifier TypeOTHER
Identifier State
Identifier IssuerCAQH

VIII. Authorized Official

Name: LADONNA CLARK
Title or Position: THERAPIST
Credential:
Phone: 919-306-0809