Provider Demographics
NPI:1902165905
Name:ACTIVE LIVING LLC
Entity Type:Organization
Organization Name:ACTIVE LIVING LLC
Other - Org Name:BEHAVIORAL CONSULTING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PBS FACILITATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:JONES
Authorized Official - Suffix:JR
Authorized Official - Credentials:NCC, QMHP
Authorized Official - Phone:434-882-3258
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-0364
Mailing Address - Country:US
Mailing Address - Phone:434-882-3258
Mailing Address - Fax:888-497-6161
Practice Address - Street 1:424 KIRBY AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-3189
Practice Address - Country:US
Practice Address - Phone:434-882-3258
Practice Address - Fax:888-497-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA174OtherPARTNERSHIP FOR PEOPLE WITH DISABILITIES VIRGINIA COMMONWEALTH UNIVERSITY