Basic Information
| Provider Information | |||||||||
| NPI: | 1588765069 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHWAY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 N 4TH ST | ||||||||
| Address2: | SUITE #103 | ||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820722091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077210700 | ||||||||
| FaxNumber: | 3077211039 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 N 4TH ST | ||||||||
| Address2: | SUITE #103 | ||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820722091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077210700 | ||||||||
| FaxNumber: | 3077211039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | HAMMER | ||||||||
| AuthorizedOfficialFirstName: | KAY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3077210700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 05617001 | 01 | WY | BLUE CROSS BLUE SHEILD | OTHER | 119619700 | 05 | WY | MEDICAID |