Basic Information
| Provider Information | |||||||||
| NPI: | 1134116536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRESSIVE STEP CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LONGVIEW THERAPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 W MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532032903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149088119 | ||||||||
| FaxNumber: | 4149087105 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 RUTH LYNN DR | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037577731 | ||||||||
| FaxNumber: | 9037573756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAASSEN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | 021675601 | 05 | TX | MEDICAID |