Provider Demographics
NPI:1821852526
Name:PERFECTLY BROKEN LLC
Entity Type:Organization
Organization Name:PERFECTLY BROKEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADDICTION COUNSELOR/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:CADC I, CRM
Authorized Official - Phone:541-429-0313
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:OR
Mailing Address - Zip Code:97882-0253
Mailing Address - Country:US
Mailing Address - Phone:541-429-0313
Mailing Address - Fax:
Practice Address - Street 1:256 E HURLBURT AVE STE 117
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2443
Practice Address - Country:US
Practice Address - Phone:541-429-0313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty