Healthcare Provider Details

I. General information

NPI: 1306527577
Provider Name (Legal Business Name): THE LIGHTED PATH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 COWBOY WAY STE 106
EDGEWOOD NM
87015-9616
US

IV. Provider business mailing address

215 COWBOY WAY STE 106
EDGEWOOD NM
87015-9616
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-7071
  • Fax: 505-508-0771
Mailing address:
  • Phone: 505-508-7071
  • Fax: 505-508-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MANDI DANIELLE ABERNATHY
Title or Position: DIRECTOR
Credential: MA, LPCC
Phone: 505-508-7071