Provider Demographics
NPI:1225139298
Name:PRO ACTIVE ADVANTAGE, LLC
Entity Type:Organization
Organization Name:PRO ACTIVE ADVANTAGE, LLC
Other - Org Name:PRO ACTIVE BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-0407
Mailing Address - Street 1:562 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5029
Mailing Address - Country:US
Mailing Address - Phone:208-734-0407
Mailing Address - Fax:208-734-3534
Practice Address - Street 1:562 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5029
Practice Address - Country:US
Practice Address - Phone:208-734-0407
Practice Address - Fax:208-734-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807373500Medicaid
ID807373500Medicaid