Provider Demographics
NPI:1376836924
Name:PROGRESSION CHILD AND ADOLESCENT CENTER LLC
Entity Type:Organization
Organization Name:PROGRESSION CHILD AND ADOLESCENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUILIFIED PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:IRVING
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:704-404-0008
Mailing Address - Street 1:4500 DAWNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-4707
Mailing Address - Country:US
Mailing Address - Phone:704-408-0004
Mailing Address - Fax:
Practice Address - Street 1:521 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3028
Practice Address - Country:US
Practice Address - Phone:980-328-1058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5966251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health