=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013574177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLOUD BREAK THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2019
-----------------------------------------------------
Last Update Date | 05/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 S WHITING ST STE 318
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22304-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-855-4330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 S WHITING ST STE 204
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22304-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-855-4330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOTHERAPIST
-----------------------------------------------------
Name | BROOKE BUCK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 703-855-4330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------