Provider Demographics
NPI:1699733600
Name:OUTREACH COMMUNITY LIVING SERVICES INC.
Entity type:Organization
Organization Name:OUTREACH COMMUNITY LIVING SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:J PENELOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC
Authorized Official - Phone:330-263-0862
Mailing Address - Street 1:337 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-4821
Mailing Address - Country:US
Mailing Address - Phone:330-263-0862
Mailing Address - Fax:330-262-8423
Practice Address - Street 1:337 W NORTH ST
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-4821
Practice Address - Country:US
Practice Address - Phone:330-263-0862
Practice Address - Fax:330-262-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0184251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0184OtherMENTAL HEALTH IDENTIFIER
OH8500232OtherMR.DD STATE IDENTIFIER
OH8500232OtherMR.DD STATE IDENTIFIER