Provider Demographics
NPI:1528820917
Name:GRACEFULLY BROKEN COUNSELING, LLC
Entity type:Organization
Organization Name:GRACEFULLY BROKEN COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:346-669-0687
Mailing Address - Street 1:11200 BROADWAY ST APT 2305
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-0136
Mailing Address - Country:US
Mailing Address - Phone:346-669-0687
Mailing Address - Fax:
Practice Address - Street 1:11200 BROADWAY ST APT 2305
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-0136
Practice Address - Country:US
Practice Address - Phone:346-669-0687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty