Healthcare Provider Details

I. General information

NPI: 1184204950
Provider Name (Legal Business Name): MAITRI PATH TO WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 PEORIA ST
PERU IL
61354-3351
US

IV. Provider business mailing address

710 PEORIA ST
PERU IL
61354-3351
US

V. Phone/Fax

Practice location:
  • Phone: 815-780-0690
  • Fax: 815-410-1937
Mailing address:
  • Phone: 815-780-0690
  • Fax: 815-410-1937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: BRENDEN FASKEN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 815-780-0690