Healthcare Provider Details

I. General information

NPI: 1578322293
Provider Name (Legal Business Name): SUPPORTIVE OUTREACH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 E BROADWAY AVE STE 1214
BISMARCK ND
58501-3395
US

IV. Provider business mailing address

3333 E BROADWAY AVE STE 1214
BISMARCK ND
58501-3395
US

V. Phone/Fax

Practice location:
  • Phone: 701-226-0621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: VERNELLE SPENCER
Title or Position: LMSW/OWNER
Credential:
Phone: 701-226-0621