Provider Demographics
NPI:1861449910
Name:MENTAL HEALTLH OUTREACH, PA
Entity Type:Organization
Organization Name:MENTAL HEALTLH OUTREACH, PA
Other - Org Name:MENTAL HEALTH OUTREACH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:817-531-8330
Mailing Address - Street 1:1725 VINEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2959
Mailing Address - Country:US
Mailing Address - Phone:817-531-8330
Mailing Address - Fax:817-531-8309
Practice Address - Street 1:1725 VINEWOOD ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2959
Practice Address - Country:US
Practice Address - Phone:817-531-8330
Practice Address - Fax:817-531-8309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
X91411Medicare UPIN
TX00324VMedicare PIN