Healthcare Provider Details

I. General information

NPI: 1528426293
Provider Name (Legal Business Name): PROGRESSIVE LIFE INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 MONTANA AVE NE
WASHINGTON DC
20002-1817
US

IV. Provider business mailing address

1933 MONTANA AVE NE
WASHINGTON DC
20002-1817
US

V. Phone/Fax

Practice location:
  • Phone: 202-349-7663
  • Fax: 202-842-0604
Mailing address:
  • Phone: 202-349-7663
  • Fax: 202-842-0604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 1060
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC301232
License Number StateDC

VIII. Authorized Official

Name: DR. FREDERICK BRIAN PHILLIPS
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 202-349-7663