Healthcare Provider Details

I. General information

NPI: 1962228486
Provider Name (Legal Business Name): NOVA FAMILY OUTREACH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 WHITE MEADOW LN
WINSTON SALEM NC
27107-5541
US

IV. Provider business mailing address

PO BOX 668352
CHARLOTTE NC
28266-8352
US

V. Phone/Fax

Practice location:
  • Phone: 704-968-2492
  • Fax:
Mailing address:
  • Phone: 704-968-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DEANNA VELAZQUEZ
Title or Position: OWNER, CLINICAL DIRECTOR
Credential: LCMHC, LCAS-A
Phone: 704-968-2492