Provider Demographics
NPI:1629639190
Name:PATHWAY PSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:PATHWAY PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:810-333-1386
Mailing Address - Street 1:1683 RIVERSIDE DR APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-2708
Mailing Address - Country:US
Mailing Address - Phone:810-333-1386
Mailing Address - Fax:
Practice Address - Street 1:22750 WOODWARD AVE STE 211
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1753
Practice Address - Country:US
Practice Address - Phone:810-333-1386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1811291818OtherNPI