Provider Demographics
NPI:1467849893
Name:PATH TO WELLNESS DBA
Entity type:Organization
Organization Name:PATH TO WELLNESS DBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR/PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:847-636-9836
Mailing Address - Street 1:6232 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 PIPER LN
Practice Address - Street 2:
Practice Address - City:PROSPECT HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60070-3613
Practice Address - Country:US
Practice Address - Phone:847-636-9836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009660251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health