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General NPI Number Information
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NPI Number | 1730200460
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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 | 04/02/2007
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Last Update Date | 09/15/2021
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Provider Practice Location Address
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Address Line | 215 UNIVERSITY DR
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City | GOODING
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State | ID
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Zip | 83330-6155
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Country | US
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Telephone | 208-934-5880
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Fax | 208-934-5876
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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 | CEO
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Name | FRANK J. KNIGHT
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Credential |
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Telephone | 208-934-5880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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