Provider Demographics
NPI:1780277293
Name:FOOTPRINTS OUTREACH AND SUPPORT
Entity type:Organization
Organization Name:FOOTPRINTS OUTREACH AND SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:APSS, CPRS, TRADPSS
Authorized Official - Phone:270-846-6335
Mailing Address - Street 1:508 CLEARVIEW ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134-2037
Mailing Address - Country:US
Mailing Address - Phone:270-846-6335
Mailing Address - Fax:
Practice Address - Street 1:618 MCELWAIN CT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3524
Practice Address - Country:US
Practice Address - Phone:270-846-6335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty