MEDICARE: RESTORATIVE PATH COUNSELING AND WELLBEING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1215607940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORATIVE PATH COUNSELING AND WELLBEING

Provider Business Mailing Address
First Line	:	22426 CANTREL WAY
Second Line	:
City	:	FARMINGTON
State	:	MN
Zip	:	55024-4011
Country	:	US
Telephone Number	:	507-676-1633
Fax Number	:

Provider Business Practice Location Address
First Line	:	22426 CANTREL WAY
Second Line	:
City	:	FARMINGTON
State	:	MN
Zip	:	55024-4011
Country	:	US
Telephone Number	:	507-676-1633
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	MRS. ATHENA MARIE DIESCH-CHHAM
Credential	:	MSW, LICSW
Telephone Number	:	507-676-1633

Provider Enumeration Date	:	09/14/2021
Last Update Date	:	09/14/2021

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