=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568116440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE COMMUNITY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2022
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 S ADAMS ST
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-861-5003
-----------------------------------------------------
Fax | 804-861-5000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 S ADAMS ST
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-861-5003
-----------------------------------------------------
Fax | 804-861-5000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. AARON LINDSAY KNIGHT
-----------------------------------------------------
Credential | QMHP A
-----------------------------------------------------
Telephone | 804-307-0497
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------