Provider Demographics
NPI:1285998716
Name:ACTIVE RECOVERY LLC
Entity type:Organization
Organization Name:ACTIVE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHAFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LAC, PLPC
Authorized Official - Phone:318-210-1539
Mailing Address - Street 1:3821 SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106
Mailing Address - Country:US
Mailing Address - Phone:318-946-8157
Mailing Address - Fax:318-216-5868
Practice Address - Street 1:3821 SOUTHERN AVE
Practice Address - Street 2:ACTIVE RECOVERY LLC
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-946-8157
Practice Address - Fax:318-216-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC 896101YA0400X
LALA1454101YA0400X
LALPC LMHP 2785251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty