Healthcare Provider Details

I. General information

NPI: 1780063651
Provider Name (Legal Business Name): PROGRESSIVE BEHAVIOR CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 ROSEBERRY CIR
PORT WENTWORTH GA
31407-5612
US

IV. Provider business mailing address

6 ROSEBERRY CIR
PORT WENTWORTH GA
31407-5612
US

V. Phone/Fax

Practice location:
  • Phone: 850-567-5657
  • Fax:
Mailing address:
  • Phone: 850-567-5657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRANDON CLARK
Title or Position: BEHAVIOR ANALYST
Credential: M.A.
Phone: 850-567-5657