Provider Demographics
NPI:1992825780
Name:MED PATH PROFESSIONAL SERVICES, INC.
Entity Type:Organization
Organization Name:MED PATH PROFESSIONAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEBSTER-FABAYO
Authorized Official - Suffix:
Authorized Official - Credentials:MS PSYCHOLOGY
Authorized Official - Phone:678-284-9010
Mailing Address - Street 1:4030 N HENRY BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7413
Mailing Address - Country:US
Mailing Address - Phone:678-284-9010
Mailing Address - Fax:678-284-9020
Practice Address - Street 1:4030 N HENRY BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7413
Practice Address - Country:US
Practice Address - Phone:678-284-9010
Practice Address - Fax:678-284-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health