Provider Demographics
NPI:1164861241
Name:PROVANCHER, NATASHA J (LMFT)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:J
Last Name:PROVANCHER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 W. EAGER ST
Mailing Address - Street 2:SUITE 313
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5467
Mailing Address - Country:US
Mailing Address - Phone:443-286-1125
Mailing Address - Fax:
Practice Address - Street 1:10 W. EAGER ST
Practice Address - Street 2:SUITE 313
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5467
Practice Address - Country:US
Practice Address - Phone:443-286-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM620106H00000X
CT001585106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist