Provider Demographics
NPI:1003145665
Name:SAM/OUTREACH PROGRAM
Entity Type:Organization
Organization Name:SAM/OUTREACH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSALIND
Authorized Official - Middle Name:TERRELLE
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-740-6512
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28093-1710
Mailing Address - Country:US
Mailing Address - Phone:704-740-6512
Mailing Address - Fax:704-735-4995
Practice Address - Street 1:114 E MAIN ST
Practice Address - Street 2:STE. B
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-2725
Practice Address - Country:US
Practice Address - Phone:704-740-6512
Practice Address - Fax:704-735-4995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-055-114174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty