Healthcare Provider Details

I. General information

NPI: 1811640592
Provider Name (Legal Business Name): BREAKWATER PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 SE 6TH AVE STE 200
DELRAY BEACH FL
33483-5306
US

IV. Provider business mailing address

5949 NW 63RD WAY
PARKLAND FL
33067-1525
US

V. Phone/Fax

Practice location:
  • Phone: 954-372-6582
  • Fax:
Mailing address:
  • Phone: 641-485-8750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: BENJAMIN PAUL HEINRICHS
Title or Position: COFOUNDER
Credential: MA, LMHC
Phone: 954-372-6582