Basic Information
| Provider Information | |||||||||
| NPI: | 1376060624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRECKENRIDGE COUNSELING SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 98 E MCBEE AVE UNIT 314 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322458505 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N MAIN ST STE 301E | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296015104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322458505 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2017 | ||||||||
| LastUpdateDate: | 08/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | VAN FOSSAN | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/SOLE PRACTIONER | ||||||||
| AuthorizedOfficialTelephone: | 7322458505 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LISW-CP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12010 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.