Provider Demographics
NPI:1972815215
Name:PROVOST, MICHELLE NICOLE (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 NE 109TH CT
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6177
Mailing Address - Country:US
Mailing Address - Phone:360-558-5711
Mailing Address - Fax:360-695-0628
Practice Address - Street 1:5501 NE 109TH CT
Practice Address - Street 2:SUITE A-1
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6177
Practice Address - Country:US
Practice Address - Phone:360-558-5711
Practice Address - Fax:360-695-0628
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60161771101YM0800X
CA060222650101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool