Healthcare Provider Details

I. General information

NPI: 1285330043
Provider Name (Legal Business Name): BREAKWATER PSYCHIATRY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 02/03/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 HUMPHREY ST
SWAMPSCOTT MA
01907-2574
US

IV. Provider business mailing address

17 PARADISE ROAD VINNIN SQUARE PLAZA #1021
SALEM MA
01970
US

V. Phone/Fax

Practice location:
  • Phone: 781-205-9496
  • Fax:
Mailing address:
  • Phone: 781-205-9496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MEGAN ANN CAVANAUGH
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 781-205-9496