Provider Demographics
NPI:1780077784
Name:BREAKAWAY PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:BREAKAWAY PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:410-721-6333
Mailing Address - Street 1:PO BOX 4704
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-4704
Mailing Address - Country:US
Mailing Address - Phone:410-721-6333
Mailing Address - Fax:410-721-7651
Practice Address - Street 1:2138 PRIEST BRIDGE CT STE 7
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2463
Practice Address - Country:US
Practice Address - Phone:410-721-6333
Practice Address - Fax:410-721-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-15
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty