Healthcare Provider Details

I. General information

NPI: 1912624495
Provider Name (Legal Business Name): GRACEFUL PATHWAYS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 US 49 SUITE E
GULFPORT MS
39503-3950
US

IV. Provider business mailing address

4509 JEFFERSON AVE
GULFPORT MS
39507-4022
US

V. Phone/Fax

Practice location:
  • Phone: 228-707-2007
  • Fax:
Mailing address:
  • Phone: 228-669-4367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JODI RENEE KLUBNIK
Title or Position: OWNER/DIRECTOR
Credential: LCSW
Phone: 228-669-4367