Provider Demographics
NPI:1225579162
Name:ANNETTE PROVENCHER LCSW LLC
Entity Type:Organization
Organization Name:ANNETTE PROVENCHER LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENCHER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:732-876-3094
Mailing Address - Street 1:39 AVENUE AT THE CMN
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4807
Mailing Address - Country:US
Mailing Address - Phone:732-876-3094
Mailing Address - Fax:
Practice Address - Street 1:24 CHAPMAN TER
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-1563
Practice Address - Country:US
Practice Address - Phone:732-876-3094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC048231001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty