Healthcare Provider Details

I. General information

NPI: 1184275117
Provider Name (Legal Business Name): PROACTIVE BEHAVIOR THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12573 CHILLICOTHE RD
CHESTERLAND OH
44026-2536
US

IV. Provider business mailing address

12573 CHILLICOTHE RD
CHESTERLAND OH
44026-2536
US

V. Phone/Fax

Practice location:
  • Phone: 440-201-9181
  • Fax: 855-960-0149
Mailing address:
  • Phone: 440-201-9181
  • Fax: 855-960-0149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LEAH CHRISTINE GONGOLA
Title or Position: DIRECTOR
Credential: PHD, BCBA-D, COBA
Phone: 440-313-8636