Healthcare Provider Details

I. General information

NPI: 1427442169
Provider Name (Legal Business Name): BROKEN BUT YET HEALED THERAPEUTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 E 13TH ST SUITE 227
ANNISTON AL
36201-4601
US

IV. Provider business mailing address

PO BOX 19862
BIRMINGHAM AL
35219-0862
US

V. Phone/Fax

Practice location:
  • Phone: 334-392-0105
  • Fax:
Mailing address:
  • Phone: 334-392-0105
  • Fax: 888-892-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC2251A
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2251A
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberC2251A
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: LASHEENA DAVIS
Title or Position: OWNER
Credential: M.S., ALC
Phone: 209-752-0290