Provider Demographics
NPI:1376979781
Name:PROVENZANO, TOBI MOORE
Entity Type:Individual
Prefix:MS
First Name:TOBI
Middle Name:MOORE
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MANHATTAN
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058
Mailing Address - Country:US
Mailing Address - Phone:504-544-6029
Mailing Address - Fax:504-349-8686
Practice Address - Street 1:8501 MANHATTAN
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058
Practice Address - Country:US
Practice Address - Phone:504-544-6029
Practice Address - Fax:504-349-8686
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool