Provider Demographics
NPI:1912686197
Name:PROACTIVE BEHAVIOR THERAPY
Entity Type:Organization
Organization Name:PROACTIVE BEHAVIOR THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER AND CEO
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 ROAD
Mailing Address - Street 2:
Mailing Address - City:CHESTERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44026
Mailing Address - Country:US
Mailing Address - Phone:440-313-8636
Mailing Address - Fax:855-960-0149
Practice Address - Street 1:12573 CHILLICOTHE ROAD
Practice Address - Street 2:
Practice Address - City:CHESTERLAND
Practice Address - State:OH
Practice Address - Zip Code:44026
Practice Address - Country:US
Practice Address - Phone:440-313-8636
Practice Address - Fax:855-960-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0477305Medicaid