Provider Demographics
NPI:1497414221
Name:PROVO, TAMMI LORRAIN
Entity Type:Individual
Prefix:MRS
First Name:TAMMI
Middle Name:LORRAIN
Last Name:PROVO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TAMMI
Other - Middle Name:LORRAIN
Other - Last Name:PROVO-FERRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:919 ANVIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-6111
Mailing Address - Country:US
Mailing Address - Phone:817-209-5036
Mailing Address - Fax:
Practice Address - Street 1:919 ANVIL CREEK DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-6111
Practice Address - Country:US
Practice Address - Phone:817-209-5036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty