Healthcare Provider Details

I. General information

NPI: 1447935895
Provider Name (Legal Business Name): BREAKTHROUGH EDUCATION SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 LAKE BLVD WL-228
DAVIS CA
95616-2614
US

IV. Provider business mailing address

1260 LAKE BLVD
DAVIS CA
95616-2614
US

V. Phone/Fax

Practice location:
  • Phone: 530-219-4309
  • Fax:
Mailing address:
  • Phone: 530-219-4309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ROWAN E FOLEY
Title or Position: OWNER
Credential: LEP
Phone: 530-219-4309