Provider Demographics
NPI:1518110139
Name:CAROLINA OUTREACH, LLC
Entity Type:Organization
Organization Name:CAROLINA OUTREACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CAROLINA OUTREACH WEST
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLOW
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:828-505-1762
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 1:18 REGENT PARK BLVD STE A
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-3727
Practice Address - Country:US
Practice Address - Phone:828-505-1762
Practice Address - Fax:828-505-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006593Medicaid