Provider Demographics
NPI:1649621962
Name:BROKEN CYCLE
Entity type:Organization
Organization Name:BROKEN CYCLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:K
Authorized Official - Last Name:COUTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-851-4640
Mailing Address - Street 1:2825 SW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-3906
Mailing Address - Country:US
Mailing Address - Phone:954-851-4640
Mailing Address - Fax:
Practice Address - Street 1:2825 SW 14TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-3906
Practice Address - Country:US
Practice Address - Phone:954-851-4640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 14023101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty