=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164066395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREAKING BARRIERS - HOPE IS ALIVE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2019
-----------------------------------------------------
Last Update Date | 02/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1920 SCHNEIDER ST NE
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44721-3352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-414-5960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 534
-----------------------------------------------------
City | UNIONTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44685-0534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-520-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. MICHELE DENISE BORNSTEIN
-----------------------------------------------------
Credential | CDCA
-----------------------------------------------------
Telephone | 330-414-5960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------