Active NPI
Breakaway Physical Therapy, LLC
- Physical Therapist
- Crofton, MD
National Provider Identifier
1780077784
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- Legal business name
- BREAKAWAY PHYSICAL THERAPY, LLC
- Practice address
- 2138 Priest Bridge CT Ste 7
Crofton, MD 21114-2463 - Phone
- (410) 721-6333
- Fax
- (410) 721-7651
- NPI assigned
- Mar 15, 2015
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mrs. Shaina Clemons, DPT
- Title
- Owner
- Phone
- (410) 721-6333
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | Primary |
Addresses
Primary practice location
2138 Priest Bridge CT Ste 7
Crofton, MD 21114-2463
Mailing address
PO Box 4704
Crofton, MD 21114-4704
Phone (410) 721-6333
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MD
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20150702000337 | MD | Part B Supplier - Physical/Occupational Therapy Group in Private Practice | 8123330222 |
Receives reassigned benefits from 9 practitioners Practice locations: Crofton, MD |
National Provider Directory
National Provider DirectoryLocations
2138 Priest Bridge Ct
Ste 7
Crofton, MD 21114
Phone (301) 807-8972
2130 Priest Bridge Dr
Ste 2
Crofton, MD 21114
Phone (301) 807-8972
Practitioners & affiliated clinicians
Practitioners 9
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1426377600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1603670400000",
"number": "1780077784",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 4704",
"city": "CROFTON",
"state": "MD",
"postal_code": "211144704",
"telephone_number": "410-721-6333",
"fax_number": "410-721-7651"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2138 PRIEST BRIDGE CT STE 7",
"city": "CROFTON",
"state": "MD",
"postal_code": "211142463",
"telephone_number": "410-721-6333",
"fax_number": "410-721-7651"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "BREAKAWAY PHYSICAL THERAPY, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2015-03-15",
"last_updated": "2020-10-26",
"certification_date": "2020-10-26",
"status": "A",
"authorized_official_last_name": "CLEMONS",
"authorized_official_first_name": "SHAINA",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "410-721-6333",
"authorized_official_name_prefix": "Mrs.",
"authorized_official_credential": "DPT"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Physical Therapist",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Crofton, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.