Organization
PROGRESSIVE BEHAVIOR SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK WISEMAN LPC (OWNER)
(208) 919-9706
Entity
Organization
Contact information
Practice address
9424 W FAIRVIEW AVE, BOISE, ID 83704-8101
(208) 375-3888
(208) 375-9444
Mailing address
3321 S STANFORD ST, NAMPA, ID 83686-8292
(208) 919-9706
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807381600
—
ID
Enumeration date
05/17/2007
Last updated
10/16/2009
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