MEDICARE: INNOVATIVE PATHWAYS INC.

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	252Y00000X	Early Intervention Provider Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1407000896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PATHWAYS INC.

Provider Business Mailing Address
First Line	:	1534 PLAZA LN
Second Line	:	SUITE 358
City	:	BURLINGAME
State	:	CA
Zip	:	94010-3204
Country	:	US
Telephone Number	:	510-206-2030
Fax Number	:	650-259-0332

Provider Business Practice Location Address
First Line	:	14895 E 14TH ST
Second Line	:	SUITE 465
City	:	SAN LEANDRO
State	:	CA
Zip	:	94578-2922
Country	:	US
Telephone Number	:	510-206-2030
Fax Number	:	510-346-7101

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. BAHRIG MIKAELIAN
Credential	:	MA
Telephone Number	:	510-206-2030

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	04/26/2012

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