Provider Demographics
NPI:1083259345
Name:A PATH TO PEACE LLC
Entity Type:Organization
Organization Name:A PATH TO PEACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELBA
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC NCC
Authorized Official - Phone:231-343-0630
Mailing Address - Street 1:9339 PINE ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3419
Mailing Address - Country:US
Mailing Address - Phone:231-343-0630
Mailing Address - Fax:
Practice Address - Street 1:1010 ANTIETAM AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2832
Practice Address - Country:US
Practice Address - Phone:231-343-0630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty