MEDICARE: CLOUD BREAK THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710448725	OTHER	VA	NPPES NPI NUMBER
2	1295073161	OTHER	VA	NPPES NPI NUMBER

General Provider Information

NPI Number	:	1013574177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLOUD BREAK THERAPY, LLC

Provider Business Mailing Address
First Line	:	101 S WHITING ST STE 204
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-3416
Country	:	US
Telephone Number	:	703-855-4330
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 S WHITING ST STE 318
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-3416
Country	:	US
Telephone Number	:	703-855-4330
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOTHERAPIST
Name	:	BROOKE BUCK
Credential	:	LPC
Telephone Number	:	703-855-4330

Provider Enumeration Date	:	05/23/2019
Last Update Date	:	05/14/2024

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