Healthcare Provider Details

I. General information

NPI: 1538075197
Provider Name (Legal Business Name): MEMORY PATH WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 LUCY LOOP
STATEN ISLAND NY
10312-3660
US

IV. Provider business mailing address

42 LUCY LOOP
STATEN ISLAND NY
10312-3660
US

V. Phone/Fax

Practice location:
  • Phone: 917-997-8234
  • Fax: 718-967-6244
Mailing address:
  • Phone: 917-997-8234
  • Fax: 718-967-6244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MICHELE HANSEN
Title or Position: OWNER
Credential: MA, CCC-SLP
Phone: 917-997-8234