=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952660698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HEALING PATH, FAMILY COUNSELING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2012
-----------------------------------------------------
Last Update Date | 05/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 HOLLYWOOD BLVD
-----------------------------------------------------
City | WEST MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32904-7418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-506-4625
-----------------------------------------------------
Fax | 321-723-8233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3565 HAMMOCK TRL
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32934-8321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-506-4625
-----------------------------------------------------
Fax | 321-723-8233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEBORAH LYNN NICKENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-506-4625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | IMH8021
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------