Provider Demographics
NPI:1306229695
Name:PROACTIVE SUPPORT COORDINATION AGENCY LLC
Entity Type:Organization
Organization Name:PROACTIVE SUPPORT COORDINATION AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ABOUBAKAR
Authorized Official - Middle Name:SIDIKI
Authorized Official - Last Name:SYLLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-880-5076
Mailing Address - Street 1:3019 S 68TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-3321
Mailing Address - Country:US
Mailing Address - Phone:215-880-5076
Mailing Address - Fax:
Practice Address - Street 1:4949 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2669
Practice Address - Country:US
Practice Address - Phone:215-613-6290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-03
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management