=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376836924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSION CHILD AND ADOLESCENT CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2011
-----------------------------------------------------
Last Update Date | 05/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 NORTH AVE
-----------------------------------------------------
City | ROCK HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29732-3028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-328-1058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 DAWNWOOD DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28212-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-408-0004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | QUILIFIED PROFESSIONAL
-----------------------------------------------------
Name | TRAVIS IRVING
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 704-404-0008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 5966
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------