Provider Demographics
NPI:1023870094
Name:PRIDE PATHWAYS PROGRAM
Entity type:Organization
Organization Name:PRIDE PATHWAYS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR PERSON
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPSCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-345-9006
Mailing Address - Street 1:3705 W PICO BLVD # 967
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3451
Mailing Address - Country:US
Mailing Address - Phone:323-200-9602
Mailing Address - Fax:
Practice Address - Street 1:770 S GRAND AVE APT 2062
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3931
Practice Address - Country:US
Practice Address - Phone:310-602-7586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-25
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty