Healthcare Provider Details

I. General information

NPI: 1558062265
Provider Name (Legal Business Name): PROGENY TMS CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17782 COWAN STE D
IRVINE CA
92614-6088
US

IV. Provider business mailing address

17782 COWAN STE A
IRVINE CA
92614-6041
US

V. Phone/Fax

Practice location:
  • Phone: 817-680-5041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JADA ALSTON
Title or Position: CO-OWNER
Credential: NP
Phone: 817-680-5041