=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083455323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT PATH MENTAL HEALTH LIMITED LIABILITY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 08/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 8TH ST N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33701-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-371-6468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4850 TAYLOR ST N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33714-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-371-6468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMIE HOAGLAND
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 727-371-6468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------