Provider Demographics
NPI:1083717326
Name:OUTREACH DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:OUTREACH DEVELOPMENT CORPORATION
Other - Org Name:OUTREACH PROJECT
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS AND CO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-847-9233
Mailing Address - Street 1:11711 MYRTLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418
Mailing Address - Country:US
Mailing Address - Phone:718-847-9233
Mailing Address - Fax:718-849-1093
Practice Address - Street 1:11711 MYRTLE AVENUE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1751
Practice Address - Country:US
Practice Address - Phone:718-847-9233
Practice Address - Fax:718-849-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081110563101YA0400X
NY061110561101YA0400X
NY070511273101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00994803Medicaid
NY00994803Medicaid
NYWEQ891Medicare ID - Type UnspecifiedCD TREATMENT SERVICES
NYWEQ892Medicare ID - Type UnspecifiedCD TREATMENT SERVICES