Provider Demographics
NPI:1790921716
Name:STEPHENS OUTREACH CENTER, INC
Entity Type:Organization
Organization Name:STEPHENS OUTREACH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:910-308-4847
Mailing Address - Street 1:105 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TABOR CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28463-1923
Mailing Address - Country:US
Mailing Address - Phone:910-653-5553
Mailing Address - Fax:
Practice Address - Street 1:105 W 5TH ST
Practice Address - Street 2:
Practice Address - City:TABOR CITY
Practice Address - State:NC
Practice Address - Zip Code:28463-1923
Practice Address - Country:US
Practice Address - Phone:910-653-5553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC251S00000X
NCMHL078149322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006568Medicaid
NC6604154Medicaid
NC8301487BMedicaid