Provider Demographics
NPI:1053727248
Name:BROKEN CHAINS INTERNATIONAL
Entity type:Organization
Organization Name:BROKEN CHAINS INTERNATIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:DALY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCPC, BCCC
Authorized Official - Phone:800-910-5060
Mailing Address - Street 1:3950 COBB PKWY NW
Mailing Address - Street 2:SUITE 902
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-9532
Mailing Address - Country:US
Mailing Address - Phone:800-910-5060
Mailing Address - Fax:800-634-6360
Practice Address - Street 1:3950 COBB PKWY NW
Practice Address - Street 2:SUITE 902
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-9532
Practice Address - Country:US
Practice Address - Phone:800-910-5060
Practice Address - Fax:800-634-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001563101Y00000X
GA09103511101YM0800X
GALPC007306101YP2500X
GAAPC003606101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty