Healthcare Provider Details

I. General information

NPI: 1467987883
Provider Name (Legal Business Name): PATH TO CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2017
Last Update Date: 04/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 TRIBBLE GAP RD STE B
CUMMING GA
30040-2475
US

IV. Provider business mailing address

314 TRIBBLE GAP RD STE B
CUMMING GA
30040-2475
US

V. Phone/Fax

Practice location:
  • Phone: 770-615-6115
  • Fax: 678-403-0334
Mailing address:
  • Phone: 770-615-6115
  • Fax: 678-403-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number007009
License Number StateGA

VIII. Authorized Official

Name: HEATHER COBB
Title or Position: OWNER
Credential: MA LPC
Phone: 770-615-6115