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General NPI Number Information
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NPI Number | 1588944151
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Entity Type | Organization
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Legal Business Name | THE OUTREACH FOUNDATION, LLC
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Dates
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Enumeration Date | 08/26/2011
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Last Update Date | 04/10/2012
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Provider Practice Location Address
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Address Line | 20 E TABB ST SUITE 201
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City | PETERSBURG
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State | VA
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Zip | 23803-4541
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Country | US
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Telephone | 888-800-0040
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Fax | 888-800-0040
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Provider Business Mailing Address
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Address Line | 20 E TABB ST SUITE 201
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City | PETERSBURG
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State | VA
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Zip | 23803-4541
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Country | US
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Telephone | 888-800-0040
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Fax | 888-800-0040
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Authorized Official
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Title or Position | EXEC OFFICER
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Name | MR. JASON MOORE
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Credential | BA
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Telephone | 888-800-0040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State | VA
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Taxonomy #2
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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 | 1630
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License Number State | VA
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