Provider Demographics
NPI:1902281843
Name:UNITY OUTREACH MINISTRIES OF AMERICA, LLC
Entity Type:Organization
Organization Name:UNITY OUTREACH MINISTRIES OF AMERICA, LLC
Other - Org Name:MAGNOLIA ANGELS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/ OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:COWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-581-3897
Mailing Address - Street 1:1122 LONDON BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2246
Mailing Address - Country:US
Mailing Address - Phone:757-581-3897
Mailing Address - Fax:
Practice Address - Street 1:1122 LONDON BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2246
Practice Address - Country:US
Practice Address - Phone:757-581-3897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001748103TC0700X
VA0001169953163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty