Provider Demographics
NPI:1780063651
Name:PROGRESSIVE BEHAVIOR CONSULTING LLC
Entity type:Organization
Organization Name:PROGRESSIVE BEHAVIOR CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:850-567-5657
Mailing Address - Street 1:6 ROSEBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-5612
Mailing Address - Country:US
Mailing Address - Phone:850-567-5657
Mailing Address - Fax:
Practice Address - Street 1:6 ROSEBERRY CIR
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-5612
Practice Address - Country:US
Practice Address - Phone:850-567-5657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health