Provider Demographics
NPI:1568949865
Name:PROGRESSIVE PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:PROGRESSIVE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DECKARD-TANKERSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-733-6629
Mailing Address - Street 1:137 MILL SPRING PL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4820
Mailing Address - Country:US
Mailing Address - Phone:177-373-3662
Mailing Address - Fax:
Practice Address - Street 1:137 MILL SPRING PL
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4820
Practice Address - Country:US
Practice Address - Phone:773-733-6629
Practice Address - Fax:386-463-2170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10079103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty