=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710687967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA OUTREACH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2023
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2508 APRIL LIU LN APT 311
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28213-6966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-332-8787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2670 DURHAM CHAPEL HILL BLVD
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27707-2829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-402-2296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JAMES MITCHELL VEDDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-844-1007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------