Healthcare Provider Details

I. General information

NPI: 1316739436
Provider Name (Legal Business Name): A LEGACY OF ABUNDANT PATHWAYS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 CHATWOOD LOOP
BLACKLICK OH
43004-3414
US

IV. Provider business mailing address

2751 CHATWOOD LOOP
BLACKLICK OH
43004-3414
US

V. Phone/Fax

Practice location:
  • Phone: 614-625-9912
  • Fax: 614-625-9912
Mailing address:
  • Phone: 614-625-9912
  • Fax: 614-625-9912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LA'BRENA SIMMONS
Title or Position: OWNER
Credential:
Phone: 614-625-9912