Provider Demographics
NPI:1225337488
Name:PROVOST, LORRAINE MARIE
Entity Type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:MARIE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 S STATE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1900
Mailing Address - Country:US
Mailing Address - Phone:810-653-3277
Mailing Address - Fax:810-653-3244
Practice Address - Street 1:1063 S STATE RD STE 1
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1900
Practice Address - Country:US
Practice Address - Phone:810-653-3277
Practice Address - Fax:810-653-3244
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501002446237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist