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General NPI Number Information
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NPI Number | 1255079133
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Entity Type | Organization
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Legal Business Name | BRAVE PATH COUNSELING PLLC
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Dates
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Enumeration Date | 05/21/2022
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Last Update Date | 05/21/2022
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Provider Practice Location Address
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Address Line | 8474 MARTIN ST
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City | CHRISTOPHER
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State | IL
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Zip | 62822-2354
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Country | US
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Telephone | 618-218-3394
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Fax |
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Provider Business Mailing Address
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Address Line | 1325 E MAIN ST # 1020
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City | CARBONDALE
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State | IL
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Zip | 62901-3116
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | COUNSELOR/ OWNER
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Name | A'NNA JURICH
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Credential | LCPC, CRADC
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Telephone | 618-218-3394
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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 |
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License Number State |
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