Provider Demographics
NPI:1235614124
Name:PROVO, IAN VICTOR
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:VICTOR
Last Name:PROVO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:IAN
Other - Middle Name:VICTOR
Other - Last Name:PROVO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:1126 POST DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4251
Mailing Address - Country:US
Mailing Address - Phone:815-229-3738
Mailing Address - Fax:
Practice Address - Street 1:1126 POST DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4251
Practice Address - Country:US
Practice Address - Phone:815-229-3738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490060491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical