Provider Demographics
NPI:1558748913
Name:OUTBOUND THERAPY LLC
Entity Type:Organization
Organization Name:OUTBOUND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COMMISSIONG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:954-687-1288
Mailing Address - Street 1:7154 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 164
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2916
Mailing Address - Country:US
Mailing Address - Phone:965-687-1288
Mailing Address - Fax:754-203-0224
Practice Address - Street 1:7154 N UNIVERSITY DR
Practice Address - Street 2:SUITE 164
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2916
Practice Address - Country:US
Practice Address - Phone:965-687-1288
Practice Address - Fax:754-203-0224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW73751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767061300Medicaid