Provider Demographics
NPI:1235969007
Name:BREAKAWAY MENTAL HEALTH, PLLC
Entity type:Organization
Organization Name:BREAKAWAY MENTAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:AEBI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:405-385-4225
Mailing Address - Street 1:116 W 7TH AVE STE 324
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4018
Mailing Address - Country:US
Mailing Address - Phone:405-385-4225
Mailing Address - Fax:
Practice Address - Street 1:116 W 7TH AVE STE 324
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4018
Practice Address - Country:US
Practice Address - Phone:405-385-4225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty