MEDICARE: PROGRESSIVE BEHAVIOR SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649487638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE BEHAVIOR SERVICES

Provider Business Mailing Address
First Line	:	3321 S STANFORD ST
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-8292
Country	:	US
Telephone Number	:	208-919-9706
Fax Number	:

Provider Business Practice Location Address
First Line	:	9424 W FAIRVIEW AVE
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8101
Country	:	US
Telephone Number	:	208-375-3888
Fax Number	:	208-375-9444

Authorized Official
Title or Position	:	OWNER
Name	:	MARK WISEMAN
Credential	:	LPC
Telephone Number	:	208-919-9706

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	10/16/2009

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Directions to “PROGRESSIVE BEHAVIOR SERVICES ” Practice Location

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