Provider Demographics
NPI:1699307173
Name:KINGDOM OUTREACH CENTER OF SAN ANTONIO, TX
Entity type:Organization
Organization Name:KINGDOM OUTREACH CENTER OF SAN ANTONIO, TX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:210-687-9715
Mailing Address - Street 1:6027 RED ROSE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-4431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:KINGDOM OUT REACH CENTER OF SAN ANTONIO
Practice Address - Street 2:3819 NACO PERRIN BLVD #118
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-687-9715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty