Provider Demographics
NPI:1427769058
Name:CREATE YOUR OWN PATH, LLC
Entity type:Organization
Organization Name:CREATE YOUR OWN PATH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:B
Authorized Official - Last Name:MEAD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:270-779-5881
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:HARDINSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40143-0360
Mailing Address - Country:US
Mailing Address - Phone:270-779-5881
Mailing Address - Fax:
Practice Address - Street 1:609 OLD HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:HARDINSBURG
Practice Address - State:KY
Practice Address - Zip Code:40143-2511
Practice Address - Country:US
Practice Address - Phone:270-779-5881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty