Provider Demographics
NPI:1356177521
Name:THE BROKEN BIRD INC.
Entity type:Organization
Organization Name:THE BROKEN BIRD INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD CAP ICRC-ADC
Authorized Official - Phone:321-440-7253
Mailing Address - Street 1:2475 PALM BAY RD NE STE 145 #27
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3362
Mailing Address - Country:US
Mailing Address - Phone:321-440-7253
Mailing Address - Fax:321-473-8426
Practice Address - Street 1:2475 PALM BAY RD NE STE 145
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-3362
Practice Address - Country:US
Practice Address - Phone:321-440-7253
Practice Address - Fax:321-473-8426
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:501(C)3
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty