Provider Demographics
NPI:1568120111
Name:PATHWAYS WELLNESS GROUP, LLP.
Entity Type:Organization
Organization Name:PATHWAYS WELLNESS GROUP, LLP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:DUREPO
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:207-492-0903
Mailing Address - Street 1:658 MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-4461
Mailing Address - Country:US
Mailing Address - Phone:207-227-3149
Mailing Address - Fax:855-553-6925
Practice Address - Street 1:658 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-4461
Practice Address - Country:US
Practice Address - Phone:207-492-0903
Practice Address - Fax:855-553-6925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECC5725OtherSTATE LICENSE