=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033350780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHWAY COUNSELING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2009
-----------------------------------------------------
Last Update Date | 03/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16239 SAINT CLAIR AVE PATHWAY COUNSELING CENTER, LLC
-----------------------------------------------------
City | EAST LIVERPOOL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43920-9449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-383-2961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1203 FAIRMONT ST PATHWAY COUNSELING CENTER, LLC
-----------------------------------------------------
City | EAST LIVERPOOL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43920-1785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-383-2961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | MRS. CASSIE LYNN DIRENZO
-----------------------------------------------------
Credential | M.S.W., L.I.S.W.
-----------------------------------------------------
Telephone | 330-383-2961
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I0700107
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------