Healthcare Provider Details

I. General information

NPI: 1992334221
Provider Name (Legal Business Name): KREATING YOUR PATH FIRM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100A SOUTHBRIDGE PKWY STE 650
BIRMINGHAM AL
35209-1377
US

IV. Provider business mailing address

429 GREEN SPRINGS HWY STE 161
BIRMINGHAM AL
35209-4938
US

V. Phone/Fax

Practice location:
  • Phone: 205-440-2685
  • Fax: 833-289-6535
Mailing address:
  • Phone: 206-642-5644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHNECE M SMITH
Title or Position: CEO, OWER
Credential: LPC, NCC
Phone: 205-643-5644