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General NPI Number Information
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NPI Number | 1124532783
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Entity Type | Organization
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Legal Business Name | HEALING PATH PSYCHOTHERAPY, LLC
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Dates
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Enumeration Date | 11/18/2017
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Last Update Date | 11/18/2017
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Provider Practice Location Address
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Address Line | 10144 N PORT WASHINGTON RD STE LL-C
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City | MEQUON
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State | WI
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Zip | 53092-5796
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Country | US
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Telephone | 262-292-1277
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Fax | 262-292-4077
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Provider Business Mailing Address
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Address Line | 11035 N HEDGEWOOD LN
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City | MEQUON
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State | WI
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Zip | 53092-4909
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Country | US
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Telephone | 262-292-1277
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Fax | 262-292-4077
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | TRICIA DAMM
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Credential |
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Telephone | 262-292-1277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4182-125
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License Number State | WI
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