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General NPI Number Information
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NPI Number | 1427446301
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Entity Type | Organization
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Legal Business Name | WELLNESS PATH
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Dates
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Enumeration Date | 12/31/2014
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Last Update Date | 12/31/2014
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Provider Practice Location Address
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Address Line | 209 OSWEGO ST SPACE#13
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City | LIVERPOOL
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State | NY
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Zip | 13088-1502
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Country | US
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Telephone | 315-457-7047
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Fax | 315-457-0719
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Provider Business Mailing Address
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Address Line | 209 OSWEGO ST SPACE#13
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City | LIVERPOOL
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State | NY
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Zip | 13088-1502
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Country | US
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Telephone | 315-457-7047
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Fax | 315-457-0719
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Authorized Official
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Title or Position | CEO
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Name | NAHID MASROURI
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Credential | LCSW-R
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Telephone | 315-457-7047
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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 | R046289-1
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License Number State | NY
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