Provider Demographics
NPI:1063894533
Name:BROKEN CHAINS INTERNATIONAL, INC
Entity type:Organization
Organization Name:BROKEN CHAINS INTERNATIONAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:DALY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCCC, BCPC
Authorized Official - Phone:678-278-8345
Mailing Address - Street 1:PO BOX 801096
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-1096
Mailing Address - Country:US
Mailing Address - Phone:678-278-8345
Mailing Address - Fax:800-634-6360
Practice Address - Street 1:3950 COBB PKWY NW
Practice Address - Street 2:SUITE 902
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-9532
Practice Address - Country:US
Practice Address - Phone:678-278-8345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 106H00000X
GALPC008385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty