Provider Demographics
NPI:1215795224
Name:YOUR PATH THERAPY GROUP, PLLC
Entity type:Organization
Organization Name:YOUR PATH THERAPY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GAGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEAVLER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:586-770-1202
Mailing Address - Street 1:17693 MAISONS DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3802
Mailing Address - Country:US
Mailing Address - Phone:586-322-5905
Mailing Address - Fax:
Practice Address - Street 1:44444 HAYES RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-7600
Practice Address - Country:US
Practice Address - Phone:586-210-6682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty