Provider Demographics
NPI:1346641602
Name:PROVENCHER, JOEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:PROVENCHER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CORPORATE DRIVE SUITE 280
Mailing Address - Street 2:CENTRA HEALTHCARE SOLUTIONS
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-3634
Mailing Address - Country:US
Mailing Address - Phone:954-636-2525
Mailing Address - Fax:800-436-1011
Practice Address - Street 1:1000 CORPORATE DRIVE SUITE 280
Practice Address - Street 2:CENTRA HEALTHCARE SOLUTIONS
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334-3634
Practice Address - Country:US
Practice Address - Phone:954-636-2525
Practice Address - Fax:800-436-1011
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0069652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist