Provider Demographics
NPI:1306378906
Name:PROVENCHER, LINDSEY (PCCI)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2506
Mailing Address - Country:US
Mailing Address - Phone:209-525-5080
Mailing Address - Fax:
Practice Address - Street 1:707 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2506
Practice Address - Country:US
Practice Address - Phone:209-525-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI2758101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional