Provider Demographics
| NPI: | 1376866160 |
|---|---|
| Name: | BREAKTHROUGH BELIEVERS RECOVERY AND HEALING CENTER |
| Entity type: | Organization |
| Organization Name: | BREAKTHROUGH BELIEVERS RECOVERY AND HEALING CENTER |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | MRS |
| Authorized Official - First Name: | PAMELA |
| Authorized Official - Middle Name: | MARIE |
| Authorized Official - Last Name: | DUVALLRICHARDSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | ABA, MAJOR SOCIOLOGY |
| Authorized Official - Phone: | 231-343-2753 |
| Mailing Address - Street 1: | 7115 DURANGO CREEK DR |
| Mailing Address - Street 2: | |
| Mailing Address - City: | MAGNOLIA |
| Mailing Address - State: | TX |
| Mailing Address - Zip Code: | 77354-2782 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 231-343-2753 |
| Mailing Address - Fax: | 231-343-2753 |
| Practice Address - Street 1: | 7115 DURANGO CREEK DR |
| Practice Address - Street 2: | |
| Practice Address - City: | MAGNOLIA |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 77354-2782 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 231-343-2753 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | BREAKTHROUGH BELIEVERS RECOVERY AND HEALING CENTER |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2010-03-08 |
| Last Update Date: | 2025-12-04 |
| Deactivation Date: | 2024-11-13 |
| Deactivation Code: | |
| Reactivation Date: | 2025-06-23 |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| MI | 610081 | 253Z00000X, 251B00000X, 347C00000X |
| 172V00000X, 363LP0808X | ||
| MI | 410357 | 1041C0700X, 363LP2300X, 103TP2701X, 101YA0400X, 171M00000X, 310400000X, 305S00000X, 251S00000X, 171M00000X |
| MI | SA0410357 | 343900000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
| No | 253Z00000X | Agencies | In Home Supportive Care | Group - Multi-Specialty | |
| No | 251B00000X | Agencies | Case Management | Group - Multi-Specialty | |
| No | 172V00000X | Other Service Providers | Community Health Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Multi-Specialty |
| No | 347C00000X | Transportation Services | Private Vehicle | ||
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | ||
| No | 305S00000X | Managed Care Organizations | Point of Service | ||
| No | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | ||
| Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | 1376866160 | Other | SUBPART HEALTHCARE PROVIDER LICENSE: 410357, 610081, 700099, 110106 |
| MI | 1376866160 | Medicaid | |
| MI | 1376866160 | Medicare Oscar/Certification |
