1720979214 NPI number — PATH T0 MINDFUL BALANCED MENTAL WELLNESS, INC

Table of content: (NPI 1720979214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720979214 NPI number — PATH T0 MINDFUL BALANCED MENTAL WELLNESS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATH T0 MINDFUL BALANCED MENTAL WELLNESS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720979214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4051 DONEVA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORPARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93021-2910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-426-2612
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10315 WOODLEY AVE STE 123
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANADA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91344-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-488-1105
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2025

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
GRACIELA
Authorized Official Middle Name:
Authorized Official Title or Position:
BEHAVIORAL HEALTH THERAPIST
Authorized Official Telephone Number:
818-426-2612

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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