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General NPI Number Information
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NPI Number | 1861173486
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Entity Type | Organization
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Legal Business Name | THE BROKEN CRAYON INITIATIVE
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Dates
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Enumeration Date | 07/27/2023
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Last Update Date | 02/09/2024
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Provider Practice Location Address
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Address Line | 2443 LYNN RD STE 112
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City | RALEIGH
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State | NC
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Zip | 27612-6759
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Country | US
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Telephone | 919-968-0330
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Fax | 919-910-5546
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Provider Business Mailing Address
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Address Line | 6 ATLANTIC AVE
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City | BENSON
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State | NC
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Zip | 27504-7852
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Country | US
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Telephone | 919-798-5622
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LISETTE MCKENZIE
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Credential |
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Telephone | 919-968-0330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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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 |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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