Provider Demographics
NPI:1760664536
Name:PROVOST, NATALIE (BA)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37875 JASPER LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:OR
Mailing Address - Zip Code:97438-9751
Mailing Address - Country:US
Mailing Address - Phone:541-747-1235
Mailing Address - Fax:547-747-4722
Practice Address - Street 1:37875 JASPER LOWELL RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:OR
Practice Address - Zip Code:97438-9751
Practice Address - Country:US
Practice Address - Phone:541-747-1235
Practice Address - Fax:547-747-4722
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health