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General NPI Number Information
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NPI Number | 1790921716
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Entity Type | Organization
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Legal Business Name | STEPHENS OUTREACH CENTER, INC
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Dates
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Enumeration Date | 12/22/2008
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Last Update Date | 12/22/2008
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Provider Practice Location Address
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Address Line | 105 W 5TH ST
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City | TABOR CITY
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State | NC
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Zip | 28463-1923
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Country | US
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Telephone | 910-653-5553
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Fax |
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Provider Business Mailing Address
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Address Line | 105 W 5TH ST
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City | TABOR CITY
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State | NC
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Zip | 28463-1923
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Country | US
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Telephone | 910-653-5553
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. MELVIN J STEPHENS SR.
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Credential |
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Telephone | 910-308-4847
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | MHL078149
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | NC
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