Healthcare Provider Details

I. General information

NPI: 1346839073
Provider Name (Legal Business Name): BROKEN TO ART COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SOUTHBRIDGE PKWY STE 650
BIRMINGHAM AL
35209-1317
US

IV. Provider business mailing address

2100 SOUTHBRIDGE PKWY STE 650
BIRMINGHAM AL
35209-1317
US

V. Phone/Fax

Practice location:
  • Phone: 205-206-6977
  • Fax: 205-533-9265
Mailing address:
  • Phone: 205-206-6977
  • Fax: 205-533-9265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: LASHEENA DAVIS
Title or Position: OWNER/PROVIDER
Credential: MS, LPC, NCC
Phone: 205-206-6977