Provider Demographics
NPI:1336866466
Name:LOVE IS OUTREACH PROGRAM
Entity Type:Organization
Organization Name:LOVE IS OUTREACH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, CEI
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARQUESIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:469-831-6486
Mailing Address - Street 1:1901 SMOKEY MOUNTAIN TRL
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-4861
Mailing Address - Country:US
Mailing Address - Phone:469-831-6486
Mailing Address - Fax:
Practice Address - Street 1:1901 SMOKEY MOUNTAIN TRL
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-4861
Practice Address - Country:US
Practice Address - Phone:469-831-6486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)