Provider Demographics
NPI:1548601743
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:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
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 1:911 HAY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5313
Practice Address - Country:US
Practice Address - Phone:910-826-3694
Practice Address - Fax:910-826-3695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3410049251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300219AMedicaid