=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073313946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESILIENT PATHWAYS THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2025
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1006 NW 47TH ST STE B
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-4759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-352-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 W MAIN ST STE 196
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73102-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-352-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AQUA STEFANO
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 858-352-8840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------