Provider Demographics
NPI:1104961861
Name:WORD OF LIFE OUTREACH OF CAPE FEAR INC
Entity type:Organization
Organization Name:WORD OF LIFE OUTREACH OF CAPE FEAR INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:910-371-5300
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-0717
Mailing Address - Country:US
Mailing Address - Phone:910-371-5300
Mailing Address - Fax:910-371-5302
Practice Address - Street 1:10225 BLACKWELL RD SE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451
Practice Address - Country:US
Practice Address - Phone:910-371-5300
Practice Address - Fax:910-371-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101Y00000X, 101YP2500X, 251B00000X
101YP2500X, 103T00000X, 103TC0700X, 103TC2200X, 101YM0800X
NCMHL-010-061251S00000X
NC197253J00000X
NC3418845251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No253J00000XAgenciesFoster Care AgencyGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301346Medicaid
NC6603673Medicaid
NC6604291Medicaid
NC6603769Medicaid
NC6006100Medicaid
NC6603477Medicaid
NC6603942Medicaid
NC6604290Medicaid
NC8302371Medicaid