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General NPI Number Information
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NPI Number | 1912624495
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Entity Type | Organization
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Legal Business Name | GRACEFUL PATHWAYS INC
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Dates
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Enumeration Date | 10/25/2022
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Last Update Date | 02/13/2023
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Provider Practice Location Address
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Address Line | 11530 US 49 SUITE E
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City | GULFPORT
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State | MS
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Zip | 39503-3950
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Country | US
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Telephone | 228-707-2007
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Fax |
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Provider Business Mailing Address
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Address Line | 4509 JEFFERSON AVE
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City | GULFPORT
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State | MS
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Zip | 39507-4022
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Country | US
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Telephone | 228-669-4367
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Fax |
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | JODI RENEE KLUBNIK
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Credential | LCSW
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Telephone | 228-669-4367
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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