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General NPI Number Information
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NPI Number | 1699771212
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Entity Type | Organization
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Legal Business Name | OUTREACH 12
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Dates
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Enumeration Date | 06/28/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2208 PRIMROSE AVE STE H-A
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City | MCALLEN
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State | TX
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Zip | 78504-4155
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Country | US
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Telephone | 956-682-6889
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Fax | 956-682-6889
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Provider Business Mailing Address
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Address Line | PO BOX 147
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City | ENCINO
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State | TX
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Zip | 78353-0147
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Country | US
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Telephone | 361-325-4921
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Fax | 361-325-5768
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MRS. JACKIE SUSAN WEBSTER-NEAL
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Credential | LCDC/ADCIIID/ICADC
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Telephone | 361-568-3761
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 1918-A
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License Number State | TX
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