Provider Demographics
NPI:1245734342
Name:BREAKING DAWN LLC
Entity Type:Organization
Organization Name:BREAKING DAWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:DERAMUS
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:256-490-4443
Mailing Address - Street 1:116 WILKERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35756-4280
Mailing Address - Country:US
Mailing Address - Phone:256-490-4443
Mailing Address - Fax:
Practice Address - Street 1:116 WILKERSON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35756-4280
Practice Address - Country:US
Practice Address - Phone:256-490-4443
Practice Address - Fax:256-262-4637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health