Provider Demographics
NPI:1831560531
Name:BREAKING FREE OF ADDICTION
Entity type:Organization
Organization Name:BREAKING FREE OF ADDICTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CD COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LENNOX
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II, ICADC, SAP
Authorized Official - Phone:951-443-9758
Mailing Address - Street 1:5790 MAGNOLIA AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1874
Mailing Address - Country:US
Mailing Address - Phone:941-443-9758
Mailing Address - Fax:877-811-7190
Practice Address - Street 1:29399 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4832
Practice Address - Country:US
Practice Address - Phone:951-443-9758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRISTY LENNOX
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8250912101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A8250912OtherCERTIFICATION