Provider Demographics
NPI:1437509106
Name:PATH 2 POTENTIAL, LLC
Entity Type:Organization
Organization Name:PATH 2 POTENTIAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LANTIER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:917-270-6865
Mailing Address - Street 1:5812 QUEENS BLVD
Mailing Address - Street 2:5O
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-7765
Mailing Address - Country:US
Mailing Address - Phone:917-270-6865
Mailing Address - Fax:
Practice Address - Street 1:5812 QUEENS BLVD
Practice Address - Street 2:5O
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-7765
Practice Address - Country:US
Practice Address - Phone:917-270-6865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000710251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health