Provider Demographics
NPI:1184275117
Name:PROACTIVE BEHAVIOR THERAPY, LLC
Entity type:Organization
Organization Name:PROACTIVE BEHAVIOR THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:GONGOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA-D, COBA
Authorized Official - Phone:440-313-8636
Mailing Address - Street 1:12573 CHILLICOTHE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44026-2536
Mailing Address - Country:US
Mailing Address - Phone:440-201-9181
Mailing Address - Fax:855-960-0149
Practice Address - Street 1:12573 CHILLICOTHE RD
Practice Address - Street 2:
Practice Address - City:CHESTERLAND
Practice Address - State:OH
Practice Address - Zip Code:44026-2536
Practice Address - Country:US
Practice Address - Phone:440-201-9181
Practice Address - Fax:855-960-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty