=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346026473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOT EASILY BROKEN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2023
-----------------------------------------------------
Last Update Date | 09/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2040 LINGLESTOWN RD STE 107
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17110-9568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-999-4757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3999 SUNSET RD
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17112-3015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-805-0266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, MENTAL HEALTH COUNSELOR
-----------------------------------------------------
Name | SHANNON ASHLEY NORDT
-----------------------------------------------------
Credential | CMHC
-----------------------------------------------------
Telephone | 717-999-4757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------