Provider Demographics
NPI:1073605945
Name:PROVENZANO, RICHARD J (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-0193
Mailing Address - Country:US
Mailing Address - Phone:540-335-3715
Mailing Address - Fax:540-459-9015
Practice Address - Street 1:227 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1451
Practice Address - Country:US
Practice Address - Phone:540-335-3715
Practice Address - Fax:540-459-9015
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040021581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA089598MOtherOUTPATIENT THERAPY-OPTIMA
VA010278520Medicaid
VA197389OtherOUTPATIENT THERAPY-ANTHEM