Provider Demographics
NPI:1598227910
Name:BREAKING THE CYCLE OF ADDICTION
Entity Type:Organization
Organization Name:BREAKING THE CYCLE OF ADDICTION
Other - Org Name:BREAKING THE CYCLE OF ADDICTION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARION
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MSW/ACSW
Authorized Official - Phone:916-583-1035
Mailing Address - Street 1:6011 STACY AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-3945
Mailing Address - Country:US
Mailing Address - Phone:916-583-1035
Mailing Address - Fax:
Practice Address - Street 1:6011 STACY AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-3945
Practice Address - Country:US
Practice Address - Phone:916-583-1035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780942334OtherNPI-PERSONAL