Healthcare Provider Details

I. General information

NPI: 1407000896
Provider Name (Legal Business Name): INNOVATIVE PATHWAYS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14895 E 14TH ST SUITE 465
SAN LEANDRO CA
94578-2922
US

IV. Provider business mailing address

1534 PLAZA LN SUITE 358
BURLINGAME CA
94010-3204
US

V. Phone/Fax

Practice location:
  • Phone: 510-206-2030
  • Fax: 510-346-7101
Mailing address:
  • Phone: 510-206-2030
  • Fax: 650-259-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. BAHRIG MIKAELIAN
Title or Position: EXECUTIVE DIRECTOR
Credential: MA
Phone: 510-206-2030