MEDICARE: PROGRESSIVE PATHWAYS PSYCHIATRY PLLC

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	261QM0850X	Adult Mental Health Clinic/Center
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1285479238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE PATHWAYS PSYCHIATRY PLLC

Provider Business Mailing Address
First Line	:	1428 E ARLINGTON AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-6124
Country	:	US
Telephone Number	:	469-442-9930
Fax Number	:

Provider Business Practice Location Address
First Line	:	1428 E ARLINGTON AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-6124
Country	:	US
Telephone Number	:	469-442-9930
Fax Number	:

Authorized Official
Title or Position	:	NP
Name	:	EDOGHOGHO EDOSONMWAN
Credential	:
Telephone Number	:	469-442-9930

Provider Enumeration Date	:	06/29/2024
Last Update Date	:	08/07/2024

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