Provider Demographics
NPI:1699771212
Name:OUTREACH 12
Entity type:Organization
Organization Name:OUTREACH 12
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:WEBSTER-NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC/ADCIIID/ICADC
Authorized Official - Phone:361-568-3761
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:TX
Mailing Address - Zip Code:78353-0147
Mailing Address - Country:US
Mailing Address - Phone:361-325-4921
Mailing Address - Fax:361-325-5768
Practice Address - Street 1:2208 PRIMROSE AVE
Practice Address - Street 2:STE H-A
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-4155
Practice Address - Country:US
Practice Address - Phone:956-682-6889
Practice Address - Fax:956-682-6889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1918-A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder