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General NPI Number Information
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NPI Number | 1437509106
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Entity Type | Organization
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Legal Business Name | PATH 2 POTENTIAL, LLC
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Dates
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Enumeration Date | 06/14/2016
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Last Update Date | 06/14/2016
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Provider Practice Location Address
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Address Line | 5812 QUEENS BLVD 5O
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City | WOODSIDE
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State | NY
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Zip | 11377-7765
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Country | US
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Telephone | 917-270-6865
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Fax |
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Provider Business Mailing Address
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Address Line | 5812 QUEENS BLVD 5O
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City | WOODSIDE
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State | NY
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Zip | 11377-7765
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Country | US
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Telephone | 917-270-6865
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JASON LANTIER
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Credential | BCBA
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Telephone | 917-270-6865
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 000710
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License Number State | NY
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