Provider Demographics
NPI:1902499155
Name:BREAKWATER COUNSELING, LLC
Entity Type:Organization
Organization Name:BREAKWATER COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:508-284-2121
Mailing Address - Street 1:30 MARBLE ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-4281
Mailing Address - Country:US
Mailing Address - Phone:508-284-2121
Mailing Address - Fax:
Practice Address - Street 1:2 MAIN ST FL 3
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-5726
Practice Address - Country:US
Practice Address - Phone:508-284-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health