Provider Demographics
NPI:1093245417
Name:BROKEN PIECES SERVICES LLC
Entity Type:Organization
Organization Name:BROKEN PIECES SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARQUITTA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-258-9315
Mailing Address - Street 1:8021 BELLA VISTA CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 REMOUNT RD STE G100
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7476
Practice Address - Country:US
Practice Address - Phone:980-258-9315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X, 251B00000X, 251S00000X, 251B00000X
NC171M00000X, 175T00000X, 253Z00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Yes251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7951Medicaid