Provider Demographics
NPI:1265587968
Name:PATHWAYSMHDDSA
Entity type:Organization
Organization Name:PATHWAYSMHDDSA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRISIS CLINICAL SPECIALIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LATTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:704-476-4010
Mailing Address - Street 1:901 S NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5829
Mailing Address - Country:US
Mailing Address - Phone:704-884-2051
Mailing Address - Fax:704-669-2017
Practice Address - Street 1:901 S NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5829
Practice Address - Country:US
Practice Address - Phone:704-884-2051
Practice Address - Fax:704-669-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0013971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106220Medicaid
NCC001397OtherSOCIAL WORKER
NC2869469AMedicare ID - Type Unspecified