=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770174351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2021
-----------------------------------------------------
Last Update Date | 01/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4777 ALBEN BARKLEY DR
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-6789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-534-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4777 ALBEN BARKLEY DR
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-6789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-534-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JINNIFER L DISCHER
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 270-534-1400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------