Healthcare Provider Details

I. General information

NPI: 1003490699
Provider Name (Legal Business Name): PATHWAY TO HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13184 US HIGHWAY 301 S UNIT 13194
RIVERVIEW FL
33578-7410
US

IV. Provider business mailing address

13194 US HIGHWAY 301 S
RIVERVIEW FL
33578-7410
US

V. Phone/Fax

Practice location:
  • Phone: 813-705-7098
  • Fax:
Mailing address:
  • Phone: 813-705-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: NICOLE PANKEY
Title or Position: PRESIDENT
Credential:
Phone: 813-705-7093