Provider Demographics
NPI:1689348468
Name:PROSPERITY PATH, LLC
Entity Type:Organization
Organization Name:PROSPERITY PATH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:LILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-615-3458
Mailing Address - Street 1:12430 CLACKWYCK LN STE 704
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1628
Mailing Address - Country:US
Mailing Address - Phone:704-615-3458
Mailing Address - Fax:
Practice Address - Street 1:6638 FARMINGDALE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-4420
Practice Address - Country:US
Practice Address - Phone:704-615-3458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health