Provider Demographics
NPI:1124353339
Name:PRO- HOLISM PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PRO- HOLISM PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE ADMINISTRATION EXECUTIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:REDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMP, DSC, PSYD/PHD
Authorized Official - Phone:404-800-5550
Mailing Address - Street 1:2480 WINDY HILL RD SE STE 206
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8656
Mailing Address - Country:US
Mailing Address - Phone:404-800-5550
Mailing Address - Fax:
Practice Address - Street 1:2480 WINDY HILL RD SE
Practice Address - Street 2:SUITE 206
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8644
Practice Address - Country:US
Practice Address - Phone:770-953-0074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADMINISTRATIVE BUSINESS COUNCIL, '(ABC)' INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-06
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103TH0100X, 251S00000X, 261Q00000X, 305R00000X, 251E00000X
FL2081S0010X
251J00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization