Basic Information
| Provider Information | |||||||||
| NPI: | 1790416790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVE BEHAVIORAL GOALS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13242 HUNTERS BREEZE ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782302867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3479274409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13242 HUNTERS BREEZE ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782302867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3479274409 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2022 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROYZMAN | ||||||||
| AuthorizedOfficialFirstName: | LEONID | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3479274409 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.