Provider Demographics
NPI:1053029561
Name:BROADSTREET COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:BROADSTREET COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:313-704-4217
Mailing Address - Street 1:2919 TELEGRAPH AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3577
Mailing Address - Country:US
Mailing Address - Phone:313-704-4217
Mailing Address - Fax:
Practice Address - Street 1:2919 TELEGRAPH AVE APT 303
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3577
Practice Address - Country:US
Practice Address - Phone:313-704-4217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)