Provider Demographics
NPI:1861231664
Name:STREET OUTREACH HEALTHCARE
Entity type:Organization
Organization Name:STREET OUTREACH HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARDOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-751-7173
Mailing Address - Street 1:2379 GUS THOMASSON RD STE 400
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-5302
Mailing Address - Country:US
Mailing Address - Phone:318-751-7173
Mailing Address - Fax:
Practice Address - Street 1:2379 GUS THOMASSON RD STE 400
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-5302
Practice Address - Country:US
Practice Address - Phone:318-751-7173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251B00000XAgenciesCase Management
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder