Provider Demographics
NPI:1346009453
Name:THE OUTREACH WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:THE OUTREACH WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTAKE COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:857-939-4445
Mailing Address - Street 1:200 NEWBURY AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1354 HANCOCK ST STE 205
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5109
Practice Address - Country:US
Practice Address - Phone:857-939-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty