Provider Demographics
NPI:1568534972
Name:PROVENZOLA, DONNA LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:LYNN
Last Name:PROVENZOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 NEWBURG RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2497
Mailing Address - Country:US
Mailing Address - Phone:502-454-8800
Mailing Address - Fax:502-736-0140
Practice Address - Street 1:3430 NEWBURG RD
Practice Address - Street 2:SUITE 212
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2497
Practice Address - Country:US
Practice Address - Phone:502-454-8800
Practice Address - Fax:502-736-0140
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY20411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY369633OtherTRICARE
KY000000378907OtherANTHEM
KY814082000OtherMAGELLAN
KYCSW0298Medicare ID - Type Unspecified