Provider Demographics
NPI:1508024266
Name:PROGRESSIVE ENVIRONMENTS FOR TUSCALOOSA RESIDENTS ALLIANCE, INC
Entity Type:Organization
Organization Name:PROGRESSIVE ENVIRONMENTS FOR TUSCALOOSA RESIDENTS ALLIANCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURROUGHS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-554-0516
Mailing Address - Street 1:1717 CARRIAGE LN E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-4774
Mailing Address - Country:US
Mailing Address - Phone:205-554-0516
Mailing Address - Fax:
Practice Address - Street 1:1717 CARRIAGE LN E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-4774
Practice Address - Country:US
Practice Address - Phone:205-554-0516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health