Provider Demographics
NPI:1457819195
Name:THE BREAKAWAY CORP
Entity Type:Organization
Organization Name:THE BREAKAWAY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:502-664-7987
Mailing Address - Street 1:1514 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2844
Mailing Address - Country:US
Mailing Address - Phone:812-941-4177
Mailing Address - Fax:
Practice Address - Street 1:1514 E SPRING ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2844
Practice Address - Country:US
Practice Address - Phone:812-941-4177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility