Provider Demographics
NPI:1982120572
Name:WARRIOR'S PATH
Entity Type:Organization
Organization Name:WARRIOR'S PATH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUPERSCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-921-0119
Mailing Address - Street 1:258-A MAIN STREET
Mailing Address - Street 2:#326
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-4006
Practice Address - Country:US
Practice Address - Phone:508-921-0119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000010244101YM0800X
MA2466272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty