Provider Demographics
NPI:1659524775
Name:PROGRESSIVE CONSUMER COUNSELING
Entity Type:Organization
Organization Name:PROGRESSIVE CONSUMER COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-209-1209
Mailing Address - Street 1:6175 OLD NATIONAL HWY STE 420
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4470
Mailing Address - Country:US
Mailing Address - Phone:404-209-1209
Mailing Address - Fax:
Practice Address - Street 1:6175 OLD NATIONAL HWY STE 420
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-4470
Practice Address - Country:US
Practice Address - Phone:404-209-1209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15010372342084P0800X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA705221638AMedicaid