Healthcare Provider Details

I. General information

NPI: 1023922143
Provider Name (Legal Business Name): PATH OF CHANGE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2267 COVENTRY DR
WINTER PARK FL
32792-2214
US

IV. Provider business mailing address

3415 W LAKE MARY BLVD UNIT 950460
LAKE MARY FL
32795-7520
US

V. Phone/Fax

Practice location:
  • Phone: 904-250-2436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: COURTNEY KIANA HAYNES
Title or Position: MEMBER
Credential: LMHC
Phone: 904-250-2436