Provider Demographics
NPI:1861173486
Name:THE BROKEN CRAYON INITIATIVE
Entity type:Organization
Organization Name:THE BROKEN CRAYON INITIATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-968-0330
Mailing Address - Street 1:6 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-7852
Mailing Address - Country:US
Mailing Address - Phone:919-798-5622
Mailing Address - Fax:
Practice Address - Street 1:2443 LYNN RD STE 112
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-6759
Practice Address - Country:US
Practice Address - Phone:919-968-0330
Practice Address - Fax:919-910-5546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-27
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty