Provider Demographics
NPI:1902079437
Name:COUNTRY PATHWAYS PLLC
Entity Type:Organization
Organization Name:COUNTRY PATHWAYS PLLC
Other - Org Name:COUNTRY PATHWAYS PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHELETTE WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:903-365-2198
Mailing Address - Street 1:1804 LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3724
Mailing Address - Country:US
Mailing Address - Phone:903-850-6334
Mailing Address - Fax:
Practice Address - Street 1:108 WAIN DR STE B
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-1231
Practice Address - Country:US
Practice Address - Phone:903-850-6334
Practice Address - Fax:903-236-8510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15127101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX028036401Medicaid