Healthcare Provider Details

I. General information

NPI: 1083717326
Provider Name (Legal Business Name): OUTREACH DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11711 MYRTLE AVENUE
RICHMOND HILL NY
11418-1751
US

IV. Provider business mailing address

11711 MYRTLE AVENUE
RICHMOND HILL NY
11418
US

V. Phone/Fax

Practice location:
  • Phone: 718-847-9233
  • Fax: 718-849-1093
Mailing address:
  • Phone: 718-847-9233
  • Fax: 718-849-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number081110563
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number061110561
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number070511273
License Number StateNY

VIII. Authorized Official

Name: MS. CHRISTINE CASIANO
Title or Position: VICE PRESIDENT OF OPERATIONS AND CO
Credential:
Phone: 718-847-9233