Provider Demographics
NPI:1265529473
Name:PROGRESSIVE PSYCHOLOGICAL BEHAVIORAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:PROGRESSIVE PSYCHOLOGICAL BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:425-228-7265
Mailing Address - Street 1:304 MAIN AVE S STE 303
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-2758
Mailing Address - Country:US
Mailing Address - Phone:425-228-7265
Mailing Address - Fax:
Practice Address - Street 1:304 MAIN AVE S STE 303
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-2758
Practice Address - Country:US
Practice Address - Phone:425-228-7265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========J00566OtherBLUE SHIELD PROVIDER ID
WA=========J00566OtherBLUE SHIELD PROVIDER ID
WAAB17547Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION N