Provider Demographics
NPI:1023129947
Name:PROVOST, JOHN FRANCIS (LCSW LICENSED CERTIF)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:FRANCIS
Last Name:PROVOST
Suffix:
Gender:M
Credentials:LCSW LICENSED CERTIF
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:77 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-3608
Mailing Address - Country:US
Mailing Address - Phone:631-724-5522
Mailing Address - Fax:631-724-5546
Practice Address - Street 1:750 VETERANS HIGHWAY
Practice Address - Street 2:SUITE 205
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2943
Practice Address - Country:US
Practice Address - Phone:631-724-5522
Practice Address - Fax:631-724-5546
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYR01368411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N51003Medicare UPIN