MEDICARE: PATH TO GROWTH COUNSELING INC.

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	101YM0800X	Mental Health Counselor	105218	CA

General Provider Information

NPI Number	:	1528556651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATH TO GROWTH COUNSELING INC.

Provider Business Mailing Address
First Line	:	1015 FREMONT AVE FL 2
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-3224
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 FREMONT AVE FL 2
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-3224
Country	:	US
Telephone Number	:	626-634-2203
Fax Number	:

Authorized Official
Title or Position	:	LMFT
Name	:	JUSTIN WONG
Credential	:
Telephone Number	:	626-634-2203

Provider Enumeration Date	:	04/24/2018
Last Update Date	:	04/24/2018

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