Provider Demographics
NPI:1457473183
Name:PROVEAUX, MICHAEL PATRICK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:PROVEAUX
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 W CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5901
Mailing Address - Country:US
Mailing Address - Phone:501-960-9609
Mailing Address - Fax:
Practice Address - Street 1:20400 COLONEL GLENN RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-5323
Practice Address - Country:US
Practice Address - Phone:501-821-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1667-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical