=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861037087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDINAL PATH WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2019
-----------------------------------------------------
Last Update Date | 05/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 1/2 S 3RD ST
-----------------------------------------------------
City | RATON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87740-8774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-303-2260
-----------------------------------------------------
Fax | 575-303-4624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1343
-----------------------------------------------------
City | RATON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87740-1343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-480-3710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING CLINICIAN
-----------------------------------------------------
Name | MS. SARAH REBECCA BALES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 323-480-3710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------