=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033725825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A MINDFUL PATH TO MENTAL HEALTH INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2020
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10419 OLD PLACERVILLE RD STE 252
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95827-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-536-6030
-----------------------------------------------------
Fax | 916-244-3865
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5804 BABCOCK RD PMB 106
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78240-2134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-536-6030
-----------------------------------------------------
Fax | 916-244-3865
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. CAROLINA BONILLA JACOME
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 916-536-6030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------