=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013753235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFES PATH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2024
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 N WOODLAND BLVD STE A306
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-578-8479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 N WOODLAND BLVD STE A306
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-327-1519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIARA NIEVES
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 386-327-1519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------