MEDICARE: SYDNEY OUTLAW LMFTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	12311A	NC

General Provider Information

NPI Number	:	1699340364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY OUTLAW LMFTA

Provider Business Mailing Address
First Line	:	203 E F ST
Second Line	:
City	:	BUTNER
State	:	NC
Zip	:	27509-2052
Country	:	US
Telephone Number	:	919-699-8395
Fax Number	:

Provider Business Practice Location Address
First Line	:	7901 STRICKLAND RD STE 107
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27615-3189
Country	:	US
Telephone Number	:	919-699-8395
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2021
Last Update Date	:	05/25/2021

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