Healthcare Provider Details

I. General information

NPI: 1598564429
Provider Name (Legal Business Name): MAITRI PATH TO WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W WILLIAMS ST
WYOMING IL
61491-1347
US

IV. Provider business mailing address

710 PEORIA ST
PERU IL
61354-3262
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 TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

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