Provider Demographics
NPI:1205531852
Name:BREAKWATER THERAPY, PLLC
Entity type:Organization
Organization Name:BREAKWATER THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIERRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW, LCAS
Authorized Official - Phone:252-229-7956
Mailing Address - Street 1:5741 HIGHGROVE PL
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-4257
Mailing Address - Country:US
Mailing Address - Phone:252-229-7956
Mailing Address - Fax:
Practice Address - Street 1:330 MILITARY CUTOFF RD STE A4
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-8303
Practice Address - Country:US
Practice Address - Phone:252-229-7956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty