Provider Demographics
NPI:1255676581
Name:PROVOST, MORGAN (DPT)
Entity Type:Individual
Prefix:MS
First Name:MORGAN
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 LAKEMONT RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-9690
Mailing Address - Country:US
Mailing Address - Phone:802-334-8558
Mailing Address - Fax:802-334-8559
Practice Address - Street 1:235 LAKEMONT RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-9690
Practice Address - Country:US
Practice Address - Phone:802-334-8558
Practice Address - Fax:802-334-8559
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400086532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist