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General NPI Number Information
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NPI Number | 1235969007
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Entity Type | Organization
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Legal Business Name | BREAKAWAY MENTAL HEALTH, PLLC
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Dates
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Enumeration Date | 08/06/2024
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Last Update Date | 08/06/2024
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Provider Practice Location Address
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Address Line | 116 W 7TH AVE STE 324
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City | STILLWATER
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State | OK
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Zip | 74074-4018
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Country | US
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Telephone | 405-385-4225
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Fax |
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Provider Business Mailing Address
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Address Line | 116 W 7TH AVE STE 324
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City | STILLWATER
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State | OK
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Zip | 74074-4018
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Country | US
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Telephone | 405-385-4225
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MRS. BECKY DIANE AEBI
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Credential | LPC
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Telephone | 405-385-4225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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