Provider Demographics
NPI:1144947235
Name:ARTHUR FENNER OUTREACH CENTER LLC
Entity type:Organization
Organization Name:ARTHUR FENNER OUTREACH CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEER SUPPORT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-676-5701
Mailing Address - Street 1:1423 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-4413
Mailing Address - Country:US
Mailing Address - Phone:252-676-5701
Mailing Address - Fax:252-541-1111
Practice Address - Street 1:1423 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4413
Practice Address - Country:US
Practice Address - Phone:252-541-1235
Practice Address - Fax:252-541-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-20
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5005077Medicaid