NPIMap

Organization Active NPI

Pro Active Advantage, LLC

Doing business as Pro Active Behavioral Health

  • Community/Behavioral Health Agency
  • Gooding, ID
National Provider Identifier
1407253669
Registry record updated Sep 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
License
LPC-5654 Issued in ID
Legal business name
PRO ACTIVE ADVANTAGE, LLC
Doing business as
Pro Active Behavioral Health
Practice address
215 University Dr
Gooding, ID 83330-6155
Phone
(208) 934-5880
Fax
(208) 934-5876
NPI assigned
Dec 3, 2014
Last updated
Sep 15, 2021By the provider in NPPES
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
Pat Marecki, B.S.
Title
Human Resources
Phone
(208) 772-4935

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X LPC-5654 ID Primary

Addresses

Primary practice location

215 University Dr
Gooding, ID 83330-6155

Mailing address

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

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.

NPI Registry JSON

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

{
    "created_epoch": "1417564800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631664000000",
    "number": "1407253669",
    "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": "215 UNIVERSITY DR",
            "city": "GOODING",
            "state": "ID",
            "postal_code": "833306155",
            "telephone_number": "208-934-5880",
            "fax_number": "208-934-5876"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRO ACTIVE ADVANTAGE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-03",
        "last_updated": "2021-09-15",
        "certification_date": "2021-09-15",
        "status": "A",
        "authorized_official_last_name": "MARECKI",
        "authorized_official_first_name": "PAT",
        "authorized_official_title_or_position": "HUMAN RESOURCES",
        "authorized_official_telephone_number": "208-772-4935",
        "authorized_official_credential": "B.S."
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "ID",
            "license": "LPC-5654",
            "primary": true
        }
    ],
    "identifiers": [],
    "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 Gooding, 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.