Provider Demographics
NPI:1912624495
Name:GRACEFUL PATHWAYS INC
Entity Type:Organization
Organization Name:GRACEFUL PATHWAYS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:KLUBNIK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:228-669-4367
Mailing Address - Street 1:4509 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-4022
Mailing Address - Country:US
Mailing Address - Phone:228-669-4367
Mailing Address - Fax:
Practice Address - Street 1:11530 US 49
Practice Address - Street 2:SUITE E
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3950
Practice Address - Country:US
Practice Address - Phone:228-707-2007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty