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Organization
MAITRI PATH TO WELLNESS PLLC
Active
Organization
MAITRI PATH TO WELLNESS PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRENDEN FASKEN (CHIEF OPERATING OFFICER)
(815) 780-0690
Entity
Organization
Contact information
Practice address
710 PEORIA ST, PERU, IL 61354-3351
(815) 780-0690
(815) 410-1937
Mailing address
710 PEORIA ST, PERU, IL 61354-3351
(815) 780-0690
(815) 410-1937
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YP2500X
Professional Counselor
—
—
104100000X
Social Worker
—
—
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1184204950
—
IL
01
—
F100761217
MEDICARE
IL
Enumeration date
04/14/2021
Last updated
04/19/2024
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