Basic Information
Provider Information | |||||||||
NPI: | 1104594415 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BREAKTHROUGH TRANSITIONS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2201 S BAY ST STE B-4 | ||||||||
Address2: |   | ||||||||
City: | EUSTIS | ||||||||
State: | FL | ||||||||
PostalCode: | 327266300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076161530 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2110 N DONNELLY ST STE 500 | ||||||||
Address2: |   | ||||||||
City: | MOUNT DORA | ||||||||
State: | FL | ||||||||
PostalCode: | 327576968 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3213624176 | ||||||||
FaxNumber: | 3212565176 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2021 | ||||||||
LastUpdateDate: | 01/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCSHAN | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: | ALBERTHA | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 4076161530 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: | 01/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QH0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM2500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.