=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528730389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATH FORWARD COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2021
-----------------------------------------------------
Last Update Date | 01/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 949 WEALTHY ST SE STE 205
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-1596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-226-9238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 FITZHUGH AVE SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-1566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-226-9238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MICHAEL LEE JANKOWSKI
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 616-226-9238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------