Provider Demographics
NPI:1225108525
Name:PROVOST, LISA (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PAPAS HOLW
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2678
Mailing Address - Country:US
Mailing Address - Phone:508-280-0563
Mailing Address - Fax:
Practice Address - Street 1:100 LEDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-1075
Practice Address - Country:US
Practice Address - Phone:781-871-6550
Practice Address - Fax:781-871-5973
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor