NPIMap

Organization Active NPI

Pro Active Advantage, LLC

  • Rehabilitation Psychologist
  • Burley, ID
National Provider Identifier
1124148176
Registry record updated Sep 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rehabilitation PsychologistTaxonomy code 103TR0400X
Legal business name
PRO ACTIVE ADVANTAGE, LLC
Practice address
1369 E 16TH St Ste 2
Burley, ID 83318-2008
Phone
(208) 878-3423
Fax
(208) 878-3424
NPI assigned
Mar 30, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 15, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Frank J Knight
Title
Ceo
Phone
(208) 934-5880

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rehabilitation PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TR0400X Primary

Addresses

Primary practice location

1369 E 16TH St Ste 2
Burley, ID 83318-2008

Mailing address

562 Shoup Ave W
Twin Falls, ID 83301-5029
Phone (208) 734-0407

Other identifiers 1

IdentifierTypeStateIssuer
8073698MedicaidID

Other names 1

  • Pro Active Behavioral Health Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Pro Active Advantage LLC4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1369 E 16th St
Ste 2
Burley, ID 83318
Phone (208) 878-3423

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175212800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631664000000",
    "number": "1124148176",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "562 SHOUP AVE W",
            "city": "TWIN FALLS",
            "state": "ID",
            "postal_code": "833015029",
            "telephone_number": "208-734-0407",
            "fax_number": "208-734-3534"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1369 E 16TH ST STE 2",
            "city": "BURLEY",
            "state": "ID",
            "postal_code": "833182008",
            "telephone_number": "208-878-3423",
            "fax_number": "208-878-3424"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRO ACTIVE ADVANTAGE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-30",
        "last_updated": "2021-09-15",
        "certification_date": "2021-09-15",
        "status": "A",
        "authorized_official_last_name": "KNIGHT",
        "authorized_official_first_name": "FRANK",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "208-934-5880"
    },
    "taxonomies": [
        {
            "code": "103TR0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Rehabilitation",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8073698",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pro Active Behavioral Health",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Pro Active Behavioral Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Burley, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 15, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.