Healthcare Provider Details

I. General information

NPI: 1598227910
Provider Name (Legal Business Name): BREAKING THE CYCLE OF ADDICTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 STACY AVE
SACRAMENTO CA
95823-3945
US

IV. Provider business mailing address

6011 STACY AVE
SACRAMENTO CA
95823-3945
US

V. Phone/Fax

Practice location:
  • Phone: 916-583-1035
  • Fax:
Mailing address:
  • Phone: 916-583-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MARION CORNELIUS WOLFE JR.
Title or Position: PRESIDENT
Credential: MSW/ACSW
Phone: 916-583-1035