MEDICARE: PATHWAYS ADULT LIVING 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	320800000X	Mental Illness Community Based Residential Treatment Facility	124381	TX

General Provider Information

NPI Number	:	1619207206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHWAYS ADULT LIVING INC

Provider Business Mailing Address
First Line	:	921 W CANNON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3026
Country	:	US
Telephone Number	:	817-810-0606
Fax Number	:	817-810-0616

Provider Business Practice Location Address
First Line	:	921 W CANNON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3026
Country	:	US
Telephone Number	:	817-810-0606
Fax Number	:	817-810-0616

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. LYNDA JOYCE BRYANT
Credential	:
Telephone Number	:	817-726-2974

Provider Enumeration Date	:	01/05/2010
Last Update Date	:	01/05/2010

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