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General NPI Number Information
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NPI Number | 1578827606
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Entity Type | Organization
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Legal Business Name | THE PROGRESSIVE COUNSELING AND THERAPY CENTER, LLC
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Dates
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Enumeration Date | 07/04/2012
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Last Update Date | 10/02/2013
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Provider Practice Location Address
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Address Line | 101 DEVANT ST SUITE 606
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-2710
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Country | US
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Telephone | 678-592-9454
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Fax |
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Provider Business Mailing Address
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Address Line | 101 DEVANT ST SUITE 606
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-2710
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Country | US
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Telephone | 678-592-9454
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. WILLIE JAMES CAMPBELL SR.
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Credential | LCSW
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Telephone | 678-592-9454
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | CSW004685
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License Number State | GA
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