Provider Demographics
NPI:1184204950
Name:MAITRI PATH TO WELLNESS PLLC
Entity Type:Organization
Organization Name:MAITRI PATH TO WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FASKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-780-0690
Mailing Address - Street 1:710 PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-3351
Mailing Address - Country:US
Mailing Address - Phone:815-780-0690
Mailing Address - Fax:815-410-1937
Practice Address - Street 1:710 PEORIA ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-3351
Practice Address - Country:US
Practice Address - Phone:815-780-0690
Practice Address - Fax:815-410-1937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100761217OtherMEDICARE
IL1184204950Medicaid