Provider Demographics
NPI:1144456104
Name:PROGRESSIVE RECOVERY RESOURCES LLC
Entity type:Organization
Organization Name:PROGRESSIVE RECOVERY RESOURCES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AMEER
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:BSW, QMHP,QDDP
Authorized Official - Phone:704-891-6404
Mailing Address - Street 1:3129 CREIGHTON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6209
Mailing Address - Country:US
Mailing Address - Phone:704-891-6404
Mailing Address - Fax:
Practice Address - Street 1:3129 CREIGHTON DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6209
Practice Address - Country:US
Practice Address - Phone:704-891-6404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104100000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8700569Medicaid
NC7001430Medicaid
NC6008234Medicaid
NC8700569Medicaid