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General NPI Number Information
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NPI Number | 1912704677
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Entity Type | Organization
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Legal Business Name | BEAUTIFULLY BROKEN, LLC
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Dates
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Enumeration Date | 02/28/2025
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Last Update Date | 02/28/2025
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Provider Practice Location Address
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Address Line | 312 SCOTT ST
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City | BALTIMORE
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State | MD
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Zip | 21230-2105
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Country | US
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Telephone | 817-721-3997
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Fax |
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Provider Business Mailing Address
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Address Line | 841 E FORT AVE # 204
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City | BALTIMORE
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State | MD
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Zip | 21230-5117
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. VENUS SIMMS
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Credential | LCSW-C
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Telephone | 817-721-3997
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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