Provider Demographics
NPI:1669918199
Name:STREET OUTREACH SOLUTIONS,LLC
Entity type:Organization
Organization Name:STREET OUTREACH SOLUTIONS,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAR'DOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-771-7707
Mailing Address - Street 1:2715 MACKEY PL STE 119
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2527
Mailing Address - Country:US
Mailing Address - Phone:318-771-7707
Mailing Address - Fax:
Practice Address - Street 1:2715 MACKEY PL STE 119
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2527
Practice Address - Country:US
Practice Address - Phone:318-393-5407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-08
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
LA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)