Provider Demographics
NPI:1639595200
Name:MIRROR OF GRACE OUTREACH
Entity Type:Organization
Organization Name:MIRROR OF GRACE OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-300-4528
Mailing Address - Street 1:921 LOBDELL BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-8811
Mailing Address - Country:US
Mailing Address - Phone:225-892-9514
Mailing Address - Fax:
Practice Address - Street 1:921 LOBDELL BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-8811
Practice Address - Country:US
Practice Address - Phone:225-300-4528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMS40353488NOtherLOUISIANA SECRETARY OF STATE