Provider Demographics
NPI:1649641119
Name:BREAKTHROUGH THERAPY OF FRISCO
Entity type:Organization
Organization Name:BREAKTHROUGH THERAPY OF FRISCO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS-BLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-894-1122
Mailing Address - Street 1:2770 MAIN ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-4302
Mailing Address - Country:US
Mailing Address - Phone:469-777-8448
Mailing Address - Fax:
Practice Address - Street 1:2770 MAIN ST
Practice Address - Street 2:SUITE 125
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-4302
Practice Address - Country:US
Practice Address - Phone:469-777-8448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61178101YP2500X
TX537301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty