Provider Demographics
NPI:1427442169
Name:BROKEN BUT YET HEALED THERAPEUTIC SERVICES LLC
Entity type:Organization
Organization Name:BROKEN BUT YET HEALED THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LASHEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ALC
Authorized Official - Phone:209-752-0290
Mailing Address - Street 1:PO BOX 19862
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35219-0862
Mailing Address - Country:US
Mailing Address - Phone:334-392-0105
Mailing Address - Fax:888-892-5809
Practice Address - Street 1:7 E 13TH ST
Practice Address - Street 2:SUITE 227
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-4601
Practice Address - Country:US
Practice Address - Phone:334-392-0105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2251A101Y00000X, 101YM0800X, 103K00000X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty