Provider Demographics
NPI:1134290208
Name:PROVOST, LISA ELLEN (MS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ELLEN
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 PHYSICIANS CT
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4031
Mailing Address - Country:US
Mailing Address - Phone:812-491-7739
Mailing Address - Fax:812-491-3242
Practice Address - Street 1:6221 PHYSICIANS CT
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4031
Practice Address - Country:US
Practice Address - Phone:812-491-7739
Practice Address - Fax:812-491-3242
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000109A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health