Organization Name: | PRO ACTIVE ADVANTAGE, LLC |
NPI Number: | 1073634713 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | FRANK J. KNIGHT (CEO) |
Mailing Address: | 2223 Overland Ave Burley |
State: | ID US |
Postal Code: | 833182929 |
Phone Number: | 2088783423 |
Fax Number: | 2088783424 |
NPI Enumeration Date: | 04/02/2007 |
NPI Last Update Date: | 02/16/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |