Provider Demographics
NPI:1245782341
Name:PROACTIVE BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:PROACTIVE BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:443-678-8556
Mailing Address - Street 1:1045 TAYLOR AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21286-8317
Mailing Address - Country:US
Mailing Address - Phone:443-678-8556
Mailing Address - Fax:
Practice Address - Street 1:1045 TAYLOR AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-8331
Practice Address - Country:US
Practice Address - Phone:443-678-8556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health