Healthcare Provider Details

I. General information

NPI: 1366270779
Provider Name (Legal Business Name): PATHWAYS MENTORSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N TOWN CENTER DR UNIT 1032
LAS VEGAS NV
89144-0577
US

IV. Provider business mailing address

720 CLAXTON AVE
N LAS VEGAS NV
89084-1250
US

V. Phone/Fax

Practice location:
  • Phone: 702-718-7992
  • Fax:
Mailing address:
  • Phone: 702-718-7992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: LATONYA MILLER
Title or Position: APPLIED PSYCHOLOGIST
Credential: PSYM
Phone: 725-251-1377