Provider Demographics
NPI:1841573789
Name:BREATHING SPACE LLC
Entity Type:Organization
Organization Name:BREATHING SPACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:W
Authorized Official - Last Name:POLAK
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:207-212-9512
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-0445
Mailing Address - Country:US
Mailing Address - Phone:207-212-9512
Mailing Address - Fax:
Practice Address - Street 1:132 MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1127
Practice Address - Country:US
Practice Address - Phone:207-212-9512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3042101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty