Healthcare Provider Details

I. General information

NPI: 1588587430
Provider Name (Legal Business Name): PATHWAY CAMP MITNICK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4436 CALUMET LOOP
JASPER AL
35501-7845
US

IV. Provider business mailing address

PO BOX 311206
ENTERPRISE AL
36331-1206
US

V. Phone/Fax

Practice location:
  • Phone: 205-600-5265
  • Fax:
Mailing address:
  • Phone: 205-600-5265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALESHA BOOTH
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 334-464-5824