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General NPI Number Information
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NPI Number | 1629575212
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Entity Type | Organization
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Legal Business Name | BREAKING FREE, LLC
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Dates
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Enumeration Date | 04/10/2018
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Last Update Date | 03/26/2020
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Provider Practice Location Address
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Address Line | 165 S MAIN ST
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City | LEBANON
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State | OR
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Zip | 97355-4223
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Country | US
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Telephone | 541-405-4622
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Fax | 541-405-4381
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Provider Business Mailing Address
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Address Line | PO BOX 24
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City | JEFFERSON
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State | OR
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Zip | 97352-0024
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Country | US
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Telephone | 541-327-8099
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | MS. TAMMY RENEA KROMHOUT
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Credential |
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Telephone | 541-405-4622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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