Provider Demographics
NPI:1083723266
Name:CAROLINA OUTREACH, LLC
Entity Type:Organization
Organization Name:CAROLINA OUTREACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-251-9001
Mailing Address - Street 1:2670 DURHAM CHAPEL HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2829
Mailing Address - Country:US
Mailing Address - Phone:919-251-9001
Mailing Address - Fax:919-251-9008
Practice Address - Street 1:2670 DURHAM CHAPEL HILL BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2829
Practice Address - Country:US
Practice Address - Phone:919-251-9001
Practice Address - Fax:919-251-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83002191041C0700X, 251S00000X
NC60054181041C0700X
2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904169Medicaid
NC8300219Medicaid
NC6005418Medicaid