Provider Demographics
NPI:1467068320
Name:PROVAN, HALEY KENDALL
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:KENDALL
Last Name:PROVAN
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 1:4533 MACARTHUR BLVD STE A-2074
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2059
Mailing Address - Country:US
Mailing Address - Phone:858-232-6266
Mailing Address - Fax:
Practice Address - Street 1:4701 VON KARMAN AVE STE 330
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8136
Practice Address - Country:US
Practice Address - Phone:858-232-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128553106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist