Provider Demographics
NPI:1063828333
Name:OUTSPOKEN COUNSELING AND CONSULTING LLC
Entity Type:Organization
Organization Name:OUTSPOKEN COUNSELING AND CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LISW
Authorized Official - Phone:980-275-2505
Mailing Address - Street 1:PO BOX 8804
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-8804
Mailing Address - Country:US
Mailing Address - Phone:704-222-2810
Mailing Address - Fax:
Practice Address - Street 1:9005 TWO NOTCH RD
Practice Address - Street 2:SUITE 33
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5850
Practice Address - Country:US
Practice Address - Phone:803-386-9536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1128Medicaid