Provider Demographics
NPI:1831084813
Name:WAVE BREAK PLLC
Entity type:Organization
Organization Name:WAVE BREAK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-503-1089
Mailing Address - Street 1:2501 CHATHAM RD STE N
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1014 W IRVING PARK RD APT 11
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-7342
Practice Address - Country:US
Practice Address - Phone:386-503-1089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health