Provider Demographics
NPI:1114562956
Name:BREAKING WAVES COUNSELING, LLC
Entity Type:Organization
Organization Name:BREAKING WAVES COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNICE
Authorized Official - Middle Name:SANDRA
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:520-425-1316
Mailing Address - Street 1:951 W ORANGE GROVE RD APT 3103
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-4003
Mailing Address - Country:US
Mailing Address - Phone:520-425-1316
Mailing Address - Fax:
Practice Address - Street 1:2030 E BROADWAY BLVD STE 25
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5907
Practice Address - Country:US
Practice Address - Phone:520-425-1316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty