=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093405805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREAKING BOULDERS COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | W1302 N DAM RD
-----------------------------------------------------
City | HARDWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49834-9218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-617-9362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 174
-----------------------------------------------------
City | FELCH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49831-0174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-617-9362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH THERAPIST/OWNER
-----------------------------------------------------
Name | AUNASTASIA ZSIDIEWICZ
-----------------------------------------------------
Credential | LICSWA, MSW
-----------------------------------------------------
Telephone | 414-617-9362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------