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General NPI Number Information
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NPI Number | 1598564429
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Entity Type | Organization
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Legal Business Name | MAITRI PATH TO WELLNESS, PLLC
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Dates
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Enumeration Date | 03/12/2025
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 101 W WILLIAMS ST
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City | WYOMING
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State | IL
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Zip | 61491-1347
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Country | US
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Telephone | 815-780-0690
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Fax | 815-410-1937
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Provider Business Mailing Address
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Address Line | 710 PEORIA ST
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City | PERU
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State | IL
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Zip | 61354-3262
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Country | US
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Telephone | 815-780-0690
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Fax | 815-410-1937
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | BRENDEN FASKEN
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Credential |
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Telephone | 815-780-0690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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