Provider Demographics
NPI:1336769561
Name:BREAKTHROUGH THERAPEUTIC CONCEPTS, LLC.
Entity Type:Organization
Organization Name:BREAKTHROUGH THERAPEUTIC CONCEPTS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:410-841-4448
Mailing Address - Street 1:408 CRAIN HWY S STE 6
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3661
Mailing Address - Country:US
Mailing Address - Phone:410-841-4448
Mailing Address - Fax:
Practice Address - Street 1:408 CRAIN HWY S STE 6
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3661
Practice Address - Country:US
Practice Address - Phone:410-841-4448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DM210001OtherBCBS PROVIDER ID