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General NPI Number Information
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NPI Number | 1225139298
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Entity Type | Organization
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Legal Business Name | PRO ACTIVE ADVANTAGE, LLC
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 562 SHOUP AVE W
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City | TWIN FALLS
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State | ID
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Zip | 83301-5029
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Country | US
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Telephone | 208-734-0407
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Fax | 208-734-3534
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Provider Business Mailing Address
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Address Line | 562 SHOUP AVE W
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City | TWIN FALLS
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State | ID
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Zip | 83301-5029
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Country | US
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Telephone | 208-734-0407
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Fax | 208-734-3534
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LISA COLWELL
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Credential |
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Telephone | 208-734-0407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | ID
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