Provider Demographics
NPI:1104998657
Name:PROGRESSIVE BEHAVIORAL CLINIC,LLC
Entity type:Organization
Organization Name:PROGRESSIVE BEHAVIORAL CLINIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIRT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-385-1147
Mailing Address - Street 1:1202 VICTOR II BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-1333
Mailing Address - Country:US
Mailing Address - Phone:985-385-1147
Mailing Address - Fax:985-385-3934
Practice Address - Street 1:1202 VICTOR II BLVD
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1333
Practice Address - Country:US
Practice Address - Phone:985-385-1147
Practice Address - Fax:985-385-3934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CJ51Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER