Healthcare Provider Details

I. General information

NPI: 1104384445
Provider Name (Legal Business Name): BREAKING BARRIERS WELLNESS AND COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 CENTERVIEW DR STE 200
RALEIGH NC
27606-3386
US

IV. Provider business mailing address

5540 CENTERVIEW DR STE 200
RALEIGH NC
27606-3386
US

V. Phone/Fax

Practice location:
  • Phone: 919-559-5568
  • Fax: 919-371-5599
Mailing address:
  • Phone: 919-559-5568
  • Fax: 919-371-5599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARECIUS SAMUEL
Title or Position: CEO/MENTAL HEALTH CLINICIAN
Credential: LPC
Phone: 919-559-5568