Provider Demographics
NPI:1790302487
Name:AN OUT OF THE BOX EXPERIENCE, P.C.
Entity Type:Organization
Organization Name:AN OUT OF THE BOX EXPERIENCE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENI
Authorized Official - Middle Name:SANITA
Authorized Official - Last Name:CHURCH-HINES
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:984-222-9272
Mailing Address - Street 1:4801 SWANNS MILL DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-1493
Mailing Address - Country:US
Mailing Address - Phone:984-222-9272
Mailing Address - Fax:
Practice Address - Street 1:131 SOUTHERLAND ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-2315
Practice Address - Country:US
Practice Address - Phone:984-222-9272
Practice Address - Fax:919-339-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty