Provider Demographics
NPI:1356686950
Name:PROVOST, DANIELLE K (PT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:K
Last Name:PROVOST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-2807
Mailing Address - Country:US
Mailing Address - Phone:413-204-8648
Mailing Address - Fax:
Practice Address - Street 1:60 E SILVER ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-4434
Practice Address - Country:US
Practice Address - Phone:413-562-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist