=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093463762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATH FORWARD THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2022
-----------------------------------------------------
Last Update Date | 03/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 NASSAU ST STE 400
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08542-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-316-6696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 BROEMEL PL UNIT 65
-----------------------------------------------------
City | PENNINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08534-8001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-933-5577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MR. FRANK W THEWES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 609-316-6696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------