Provider Demographics
NPI:1598336232
Name:PATH FORWARD COUNSELING LICENSED CLINICAL SOCIAL WORKER SERVICES, INC
Entity Type:Organization
Organization Name:PATH FORWARD COUNSELING LICENSED CLINICAL SOCIAL WORKER SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:III
Authorized Official - Credentials:LCSW
Authorized Official - Phone:818-642-6244
Mailing Address - Street 1:11218 LA MAIDA ST APT 102
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-4594
Mailing Address - Country:US
Mailing Address - Phone:818-642-6244
Mailing Address - Fax:818-368-8940
Practice Address - Street 1:17075 DEVONSHIRE ST STE 204
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5408
Practice Address - Country:US
Practice Address - Phone:818-642-6244
Practice Address - Fax:818-368-8940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty