Provider Demographics
NPI:1770830358
Name:PROVOST, ERICA ANN (MS, CCC)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:ANN
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:MS
Other - First Name:ERICA
Other - Middle Name:ANN
Other - Last Name:MAUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC
Mailing Address - Street 1:151 TERRACE SHORES DRIVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2706
Mailing Address - Country:US
Mailing Address - Phone:561-801-3264
Mailing Address - Fax:
Practice Address - Street 1:151 TERRACE SHORES DRIVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2706
Practice Address - Country:US
Practice Address - Phone:561-801-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
FLSA12639235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist