Provider Demographics
NPI:1457800385
Name:OUTREACH NATION, CORP
Entity Type:Organization
Organization Name:OUTREACH NATION, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KHALIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-825-8080
Mailing Address - Street 1:9565 BUSINESS CENTER DR BLDG 11 SUITE A
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-825-8080
Mailing Address - Fax:909-292-4532
Practice Address - Street 1:9565 BUSINESS CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4560
Practice Address - Country:US
Practice Address - Phone:909-825-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW28947101YM0800X
CALCSW28841106H00000X
CAMFTI60442106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty