Provider Demographics
NPI: | 1376866160 |
---|---|
Name: | BREAKTHROUGH BELIEVERS RECOVERY AND HEALING CENTER |
Entity Type: | Organization |
Organization Name: | BREAKTHROUGH BELIEVERS RECOVERY AND HEALING CENTER |
Other - Org Name: | BEHAVIORAL HEALTH SERVICES, REHAB, HEALTHCARE PROVIDER, COUNSELING |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | PAM |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | DUVALL-BATEMAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | ABA, MAJOR SOCIOLOGY |
Authorized Official - Phone: | 616-272-3796 |
Mailing Address - Street 1: | 349 JACKSON AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | MUSKEGON |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49442-1114 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 231-343-2753 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 924 EASTERN AVE SE |
Practice Address - Street 2: | |
Practice Address - City: | GRAND RAPIDS |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49507-1303 |
Practice Address - Country: | US |
Practice Address - Phone: | 231-343-2753 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-03-08 |
Last Update Date: | 2019-10-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 410357 | 101YA0400X, 103TP2701X, 1041C0700X, 171M00000X, 251S00000X, 251X00000X, 252Y00000X, 305R00000X, 305S00000X, 310400000X |
MI | 610081 | 251B00000X, 253Z00000X, 347C00000X |
MI | SA410357 | 251S00000X |
MI | SA0410357 | 343900000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
No | 251B00000X | Agencies | Case Management | ||
No | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 251X00000X | Agencies | Supports Brokerage | ||
No | 252Y00000X | Agencies | Early Intervention Provider Agency | ||
No | 253Z00000X | Agencies | In Home Supportive Care | ||
No | 305R00000X | Managed Care Organizations | Preferred Provider Organization | ||
No | 305S00000X | Managed Care Organizations | Point of Service | Group - Multi-Specialty | |
No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | ||
No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | ||
No | 347C00000X | Transportation Services | Private Vehicle | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 1376866160 | Other | SUBPART HEALTHCARE PROVIDER LICENSE: 410357, 610081, 700099, 110106 |
MI | 1376866160 | Medicaid | |
MI | 1376866160 | Medicare Oscar/Certification |