Provider Demographics
NPI:1588944151
Name:THE OUTREACH FOUNDATION, LLC
Entity type:Organization
Organization Name:THE OUTREACH FOUNDATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:888-800-0040
Mailing Address - Street 1:20 E TABB ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4541
Mailing Address - Country:US
Mailing Address - Phone:888-800-0040
Mailing Address - Fax:888-800-0040
Practice Address - Street 1:20 E TABB ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4541
Practice Address - Country:US
Practice Address - Phone:888-800-0040
Practice Address - Fax:888-800-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-26
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YP2500X
VA1630261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty