Provider Demographics
NPI:1285330043
Name:BREAKWATER PSYCHIATRY INC.
Entity type:Organization
Organization Name:BREAKWATER PSYCHIATRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:781-205-9496
Mailing Address - Street 1:17 PARADISE ROAD
Mailing Address - Street 2:VINNIN SQUARE PLAZA #1021
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970
Mailing Address - Country:US
Mailing Address - Phone:781-205-9496
Mailing Address - Fax:
Practice Address - Street 1:440 HUMPHREY ST
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-2574
Practice Address - Country:US
Practice Address - Phone:781-205-9496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty