Provider Demographics
NPI:1538658372
Name:PROGRESSIVE LIFE COUNSELING, LLC
Entity Type:Organization
Organization Name:PROGRESSIVE LIFE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-316-3826
Mailing Address - Street 1:1624 CARLYLE AVE # 543
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-4558
Mailing Address - Country:US
Mailing Address - Phone:618-731-6923
Mailing Address - Fax:
Practice Address - Street 1:515 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-6583
Practice Address - Country:US
Practice Address - Phone:618-316-3826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)