Provider Demographics
NPI:1538658372
Name:PROGRESSIVE LIFE COUNSELING LLC
Entity type:Organization
Organization Name:PROGRESSIVE LIFE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DESTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-316-3826
Mailing Address - Street 1:24 BEL AIR DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-6513
Mailing Address - Country:US
Mailing Address - Phone:618-316-3826
Mailing Address - Fax:
Practice Address - Street 1:515 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-6583
Practice Address - Country:US
Practice Address - Phone:618-316-3826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)