Basic Information
Provider Information | |||||||||
NPI: | 1962163287 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | POSITIVE PATHWAYS BEHAVIORAL HEALTH: TREATMENT AND RECOVERY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 240 JOHNSTONE DR | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | MS | ||||||||
PostalCode: | 391107687 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018135878 | ||||||||
FaxNumber: | 6017385083 | ||||||||
Practice Location | |||||||||
Address1: | 1905A MISSION 66 STE 5 | ||||||||
Address2: |   | ||||||||
City: | VICKSBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 391803703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017385820 | ||||||||
FaxNumber: | 6017385083 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2022 | ||||||||
LastUpdateDate: | 01/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRIGHT | ||||||||
AuthorizedOfficialFirstName: | TIMEKA | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6018135878 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPC | ||||||||
NPICertificationDate: | 01/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 00424763 | 05 | MS |   | MEDICAID |