Provider Demographics
NPI:1821534017
Name:PROVENCIO, MAI LE (LCSW)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:LE
Last Name:PROVENCIO
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 1:7237 W POTOMAC DR
Mailing Address - Street 2:STE 220
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9146
Mailing Address - Country:US
Mailing Address - Phone:208-794-9703
Mailing Address - Fax:
Practice Address - Street 1:7237 W POTOMAC DR
Practice Address - Street 2:STE 220
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9146
Practice Address - Country:US
Practice Address - Phone:208-794-9703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-343231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical