NPIMap

Organization Active NPI

Breakaway Physical Therapy, LLC

  • Physical Therapist
  • Crofton, MD
National Provider Identifier
1780077784
Registry record updated Oct 26, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
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
Last updated
Oct 26, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 26, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Shaina Clemons, DPTNPI 1821376567
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)CodeLicenseStatePrimary
Physical TherapistGroup: 193400000X SINGLE SPECIALTY GROUP 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 IDStateProvider typePAC IDDetails
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 Directory

Locations

2130 Priest Bridge Dr
Ste 2
Crofton, MD 21114
Phone (301) 807-8972

2138 Priest Bridge Ct
Ste 7
Crofton, MD 21114
Phone (301) 807-8972

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

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.

Verify at the official NPI Registry.