=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215690490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGING PATHWAYS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2021
-----------------------------------------------------
Last Update Date | 10/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2704 SHERIDAN AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50310-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-272-5075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2704 SHERIDAN AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50310-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-272-5075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | PAMELA JEANNE NELSON-GROTRIAN
-----------------------------------------------------
Credential | L.I.S.W., M.S.W.
-----------------------------------------------------
Telephone | 515-272-5075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------