Basic Information
| Provider Information | |||||||||
| NPI: | 1164555173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE STEP CORP | ||||||||
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| OtherOrganizationName: | PROGRESSIVE STEP REHABILITATION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532032903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149088119 | ||||||||
| FaxNumber: | 4149087105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 MEDI PARK DR | ||||||||
| Address2: | SUITE 65 | ||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791062105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064687611 | ||||||||
| FaxNumber: | 8064687603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 06/15/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAASSEN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRIVACY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4149088119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 21726701 | 05 | TX | MEDICAID |