Provider Demographics
NPI:1154443588
Name:PATHWAYS FOR ENHANCED LIVING, LLC
Entity Type:Organization
Organization Name:PATHWAYS FOR ENHANCED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARYLYNN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:201-445-3307
Mailing Address - Street 1:169 DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4407
Mailing Address - Country:US
Mailing Address - Phone:201-445-3307
Mailing Address - Fax:
Practice Address - Street 1:169 DAYTON ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4407
Practice Address - Country:US
Practice Address - Phone:201-445-3307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC045071001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ077081Medicare ID - Type Unspecified