Provider Demographics
NPI:1275245292
Name:SOUTHEAST OUTPATIENT ADDICTION RECOVERY
Entity Type:Organization
Organization Name:SOUTHEAST OUTPATIENT ADDICTION RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:334-677-7627
Mailing Address - Street 1:321 WESTGATE PKWY STE 4
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-3072
Mailing Address - Country:US
Mailing Address - Phone:334-596-2486
Mailing Address - Fax:
Practice Address - Street 1:321 WESTGATE PKWY STE 4
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-3072
Practice Address - Country:US
Practice Address - Phone:334-596-2486
Practice Address - Fax:334-446-5139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty