MEDICARE: PATHWAYS PSYCHOTHERAPY, PLLC

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		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12360850	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1972003077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHWAYS PSYCHOTHERAPY, PLLC

Provider Business Mailing Address
First Line	:	9313 FOXBURROW CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-7505
Country	:	US
Telephone Number	:	919-219-6256
Fax Number	:	919-845-4805

Provider Business Practice Location Address
First Line	:	9313 FOXBURROW CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-7505
Country	:	US
Telephone Number	:	919-219-6256
Fax Number	:	919-845-4805

Authorized Official
Title or Position	:	OWNER
Name	:	STEPHANIE DAWN PHILLIPS
Credential	:	MED., LPC, NCC, CCTP
Telephone Number	:	919-219-6256

Provider Enumeration Date	:	02/15/2018
Last Update Date	:	02/15/2018

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