Provider Demographics
NPI:1376060624
Name:BRECKENRIDGE COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:BRECKENRIDGE COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN FOSSAN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:732-245-8505
Mailing Address - Street 1:98 E MCBEE AVE UNIT 314
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4881
Mailing Address - Country:US
Mailing Address - Phone:732-245-8505
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:200 N MAIN ST STE 301E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-5104
Practice Address - Country:US
Practice Address - Phone:732-245-8505
Practice Address - Fax:000-000-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC120101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty