Healthcare Provider Details

I. General information

NPI: 1699733600
Provider Name (Legal Business Name): OUTREACH COMMUNITY LIVING SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 W NORTH ST
WOOSTER OH
44691-4821
US

IV. Provider business mailing address

337 W NORTH ST
WOOSTER OH
44691-4821
US

V. Phone/Fax

Practice location:
  • Phone: 330-263-0862
  • Fax: 330-262-8423
Mailing address:
  • Phone: 330-263-0862
  • Fax: 330-262-8423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0184
License Number StateOH

VIII. Authorized Official

Name: MS. J PENELOPE KIDDER
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, LPCC
Phone: 330-263-0862