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General NPI Number Information
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NPI Number | 1265164875
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Entity Type | Organization
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Legal Business Name | OUT THE BLUE, LLC
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Dates
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Enumeration Date | 06/30/2022
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Last Update Date | 06/30/2022
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Provider Practice Location Address
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Address Line | 5 CONCOURSE PKWY
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City | ATLANTA
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State | GA
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Zip | 30328-5350
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Country | US
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Telephone | 470-827-7356
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Fax |
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Provider Business Mailing Address
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Address Line | 8205 SAINT CLAIR DR NE
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City | ATLANTA
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State | GA
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Zip | 30329-2686
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Country | US
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Telephone | 404-625-2841
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DOMINIQUE C DEW
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Credential | LCSW
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Telephone | 404-625-2841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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