Provider Demographics
NPI:1407016751
Name:PROVOL, CARY MARIE
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:MARIE
Last Name:PROVOL
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 1:550 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3212
Mailing Address - Country:US
Mailing Address - Phone:541-689-8795
Mailing Address - Fax:
Practice Address - Street 1:550 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3212
Practice Address - Country:US
Practice Address - Phone:541-689-8795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health