Provider Demographics
NPI:1225157423
Name:PROVENZANO, MICHAEL LOUIS (DC,DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:DC,DPT
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:LOUIS
Other - Last Name:PROVENZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC,DPT
Mailing Address - Street 1:16 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3002
Mailing Address - Country:US
Mailing Address - Phone:978-470-1499
Mailing Address - Fax:978-470-1408
Practice Address - Street 1:16 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3002
Practice Address - Country:US
Practice Address - Phone:978-374-0700
Practice Address - Fax:978-374-6052
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2154111N00000X
MA18057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4400518OtherUNITED HEALTH CARE
MA657211OtherHARVARD NON PRACTICE
MAY36610OtherBLUE CROSS
MA0017863OtherNEIGHBORHOOD HEALTH
MAB2008591-01OtherCIGNA
MA99428401OtherNETWORK HEALTH
MA3345755OtherAETNA
MAAA42230OtherHARVARD PILGRIM
MAY39894OtherBLUE CROSS
MA3345755OtherAETNA
MAY39894OtherBLUE CROSS