Provider Demographics
NPI:1578925335
Name:PROVEL, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:PROVEL
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 1:1333 DOMINIC ST
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08835-1956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1333 DOMINIC ST
Practice Address - Street 2:
Practice Address - City:MANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08835-1956
Practice Address - Country:US
Practice Address - Phone:973-216-0689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00699600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist