Provider Demographics
NPI:1851474225
Name:BREAKAWAY HEALTH CORPORATION
Entity type:Organization
Organization Name:BREAKAWAY HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PLASKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-957-8229
Mailing Address - Street 1:3151 AIRWAY AVE STE D1
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4622
Mailing Address - Country:US
Mailing Address - Phone:714-957-8229
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE # D-1D2
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4607
Practice Address - Country:US
Practice Address - Phone:714-957-8229
Practice Address - Fax:714-957-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300065A101YA0400X
261QM0801X, 261QR0405X, 261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300065CPOtherDHCS LICENSE