Provider Demographics
NPI:1326590670
Name:OUTLAW, AISHA (LMHC)
Entity type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10810 BOYETTE RD # 158
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-8000
Mailing Address - Country:US
Mailing Address - Phone:813-394-6804
Mailing Address - Fax:
Practice Address - Street 1:10810 BOYETTE RD # 158
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-8000
Practice Address - Country:US
Practice Address - Phone:813-394-6804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2022-10-12
Deactivation Date:2018-01-08
Deactivation Code:
Reactivation Date:2018-09-19
Provider Licenses
StateLicense IDTaxonomies
FLMH16281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health