Provider Demographics
NPI:1700124484
Name:THE PAVED ROAD
Entity Type:Organization
Organization Name:THE PAVED ROAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:HUTCHINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:949-399-1111
Mailing Address - Street 1:4060 CAMPUS DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2217
Mailing Address - Country:US
Mailing Address - Phone:949-399-1111
Mailing Address - Fax:
Practice Address - Street 1:4060 CAMPUS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2217
Practice Address - Country:US
Practice Address - Phone:949-399-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 47859106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty