Provider Demographics
NPI:1487494191
Name:BROKEN ROADS COUNSELING LLC
Entity type:Organization
Organization Name:BROKEN ROADS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:386-249-5976
Mailing Address - Street 1:3519 168TH ST
Mailing Address - Street 2:
Mailing Address - City:WELLBORN
Mailing Address - State:FL
Mailing Address - Zip Code:32094-3017
Mailing Address - Country:US
Mailing Address - Phone:386-249-5976
Mailing Address - Fax:
Practice Address - Street 1:3519 168TH ST
Practice Address - Street 2:
Practice Address - City:WELLBORN
Practice Address - State:FL
Practice Address - Zip Code:32094-3017
Practice Address - Country:US
Practice Address - Phone:386-249-5976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty