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General NPI Number Information
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NPI Number | 1891002952
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Entity Type | Organization
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Legal Business Name | OUTLOOK FORENSIC & BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 09/09/2010
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Last Update Date | 11/21/2012
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Provider Practice Location Address
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Address Line | 280 EXECUTIVE PARK DR SUITE 100
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City | CONCORD
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State | NC
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Zip | 28025-1837
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Country | US
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Telephone | 704-785-8282
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Fax | 704-785-8282
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Provider Business Mailing Address
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Address Line | 280 EXECUTIVE PARK DR SUITE 100
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City | CONCORD
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State | NC
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Zip | 28025-1837
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Country | US
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Telephone | 704-785-8282
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Fax | 704-785-8282
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JONATHAN KEITH STOUDMIRE
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Credential | M.D.
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Telephone | 704-841-3886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 200500827
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License Number State | NC
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