Provider Demographics
NPI:1356847008
Name:BROTHERHOOD OF THE BROKEN
Entity Type:Organization
Organization Name:BROTHERHOOD OF THE BROKEN
Other - Org Name:RESTORED LIFE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC, LPC, NCC
Authorized Official - Phone:623-267-5849
Mailing Address - Street 1:5411 NE 107TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6347
Mailing Address - Country:US
Mailing Address - Phone:360-558-7663
Mailing Address - Fax:360-989-1140
Practice Address - Street 1:14050 N 83RD AVE STE 290
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5650
Practice Address - Country:US
Practice Address - Phone:623-267-5849
Practice Address - Fax:360-989-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty