Provider Demographics
NPI:1700321296
Name:PATH FOR CHANGE COUNSELING, LLC
Entity Type:Organization
Organization Name:PATH FOR CHANGE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KEIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-830-6994
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-0457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:88 PARK ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-5915
Practice Address - Country:US
Practice Address - Phone:973-830-6994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05287500251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health