Provider Demographics
NPI:1376964783
Name:COMINGOUT CHRISTIAN OUTREACH ORG.
Entity Type:Organization
Organization Name:COMINGOUT CHRISTIAN OUTREACH ORG.
Other - Org Name:COMINGOUT CHRISTIAN OUTREACH ORG.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MURIEL
Authorized Official - Middle Name:CONCETTA
Authorized Official - Last Name:WALLACECER
Authorized Official - Suffix:
Authorized Official - Credentials:CERT
Authorized Official - Phone:757-508-6671
Mailing Address - Street 1:1021 NICKLAUS DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-4102
Mailing Address - Country:US
Mailing Address - Phone:757-508-6671
Mailing Address - Fax:757-934-9294
Practice Address - Street 1:1021 NICKLAUS DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-4102
Practice Address - Country:US
Practice Address - Phone:757-508-6671
Practice Address - Fax:757-934-9294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS4070266251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health