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General NPI Number Information
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NPI Number | 1427442169
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Entity Type | Organization
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Legal Business Name | BROKEN BUT YET HEALED THERAPEUTIC SERVICES LLC
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Dates
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Enumeration Date | 03/19/2015
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Last Update Date | 04/21/2015
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Provider Practice Location Address
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Address Line | 7 E 13TH ST SUITE 227
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City | ANNISTON
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State | AL
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Zip | 36201-4601
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Country | US
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Telephone | 334-392-0105
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 19862
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City | BIRMINGHAM
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State | AL
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Zip | 35219-0862
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Country | US
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Telephone | 334-392-0105
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Fax | 888-892-5809
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Authorized Official
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Title or Position | OWNER
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Name | LASHEENA DAVIS
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Credential | M.S., ALC
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Telephone | 209-752-0290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | C2251A
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | C2251A
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License Number State | AL
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Taxonomy #3
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | C2251A
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License Number State | AL
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