Provider Demographics
NPI:1699024356
Name:HIS STOREHOUSE OUTREACH, INC.
Entity Type:Organization
Organization Name:HIS STOREHOUSE OUTREACH, INC.
Other - Org Name:NOUVEAU HOPE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOPUSNAK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-713-9402
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:FL
Mailing Address - Zip Code:33576-0284
Mailing Address - Country:US
Mailing Address - Phone:813-713-9402
Mailing Address - Fax:813-283-1184
Practice Address - Street 1:39031 COUNTY ROAD 54
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-6410
Practice Address - Country:US
Practice Address - Phone:813-713-9402
Practice Address - Fax:813-283-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL102831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty