Provider Demographics
NPI:1922571041
Name:REPAIRER OF THE BREACH COUNSELING AND CONSULTANT SERVICES, LLC
Entity type:Organization
Organization Name:REPAIRER OF THE BREACH COUNSELING AND CONSULTANT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:313-451-4239
Mailing Address - Street 1:319 CHANDLER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2857
Mailing Address - Country:US
Mailing Address - Phone:313-451-4239
Mailing Address - Fax:
Practice Address - Street 1:319 CHANDLER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2857
Practice Address - Country:US
Practice Address - Phone:313-451-4239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184962763OtherNPI