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General NPI Number Information
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NPI Number | 1922571041
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Entity Type | Organization
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Legal Business Name | REPAIRER OF THE BREACH COUNSELING AND CONSULTANT SERVICES, LLC
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Dates
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Enumeration Date | 01/11/2019
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 319 CHANDLER ST
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City | DETROIT
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State | MI
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Zip | 48202-2857
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Country | US
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Telephone | 313-451-4239
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Fax |
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Provider Business Mailing Address
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Address Line | 319 CHANDLER ST
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City | DETROIT
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State | MI
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Zip | 48202-2857
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Country | US
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Telephone | 313-451-4239
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Fax |
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Authorized Official
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Title or Position | LEAD CLINICIAN
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Name | MRS. YVONNE BROOKS
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Credential | LCSW
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Telephone | 313-451-4239
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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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 | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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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 | 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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