Provider Demographics
NPI:1790317279
Name:PROACTIVE LIFE & HEALTH SERVICES
Entity Type:Organization
Organization Name:PROACTIVE LIFE & HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:SHUNDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-416-3547
Mailing Address - Street 1:925 MAIN ST STE 300-50
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3098
Mailing Address - Country:US
Mailing Address - Phone:404-416-3547
Mailing Address - Fax:
Practice Address - Street 1:925 MAIN ST STE 300-50
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3098
Practice Address - Country:US
Practice Address - Phone:404-416-3547
Practice Address - Fax:470-867-6898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty