Provider Demographics
NPI:1760639439
Name:PROVADAKES, HARRY G (MDIV)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:G
Last Name:PROVADAKES
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-3906
Mailing Address - Country:US
Mailing Address - Phone:978-459-8656
Mailing Address - Fax:978-937-2559
Practice Address - Street 1:555 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-3906
Practice Address - Country:US
Practice Address - Phone:978-459-8656
Practice Address - Fax:978-937-2559
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)