Healthcare Provider Details

I. General information

NPI: 1093019812
Provider Name (Legal Business Name): PATHWAY TO EQUANIMITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2011
Last Update Date: 01/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 VINCENNES RD TEN FORTUNE PARK, SUITE 303
INDIANAPOLIS IN
46268-3026
US

IV. Provider business mailing address

3905 VINCENNES RD TEN FORTUNE PARK, SUITE 303
INDIANAPOLIS IN
46268-3026
US

V. Phone/Fax

Practice location:
  • Phone: 317-471-3522
  • Fax: 317-471-3508
Mailing address:
  • Phone: 317-471-3522
  • Fax: 317-471-3508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000112A
License Number StateIN

VIII. Authorized Official

Name: UNCHANA THAMASAK
Title or Position: OPERATING MANAGER
Credential: LMHC, LCAC
Phone: 317-371-2373