Provider Demographics
NPI:1558728667
Name:PROVOST, ASHLEY KAY (LMSW)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:KAY
Last Name:PROVOST
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3009
Mailing Address - Country:US
Mailing Address - Phone:069-286-3254
Mailing Address - Fax:906-273-2005
Practice Address - Street 1:1209 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3009
Practice Address - Country:US
Practice Address - Phone:906-286-3254
Practice Address - Fax:906-273-2005
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801098960104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker